ganser_prenatal care capacity assessment
TRANSCRIPT
Prenatal Care Capacity Assessment in Philadelphia
Thelma Rose Ganser, Master of Public Health Candidate June 2012
A Community Based Master’s Project presented to the faculty of Drexel University School of Public Health in partial fulfillment of the Requirement for the Degree of Master of Public Health.
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AKNOWLEDGEMENTS
I would like to give special thanks to everyone who contributed to this project. Most notably my faculty advisor, Dr. Jennifer Breaux and Principal Investigator, Dr. Nathalie A. Bartle.
Additionally, I would like to thank my community preceptor, Deborah Roebuck and other members of the Maternal, Child and Family Health Division of the Philadelphia Department of
Public Health including Maria Ness and Bethany Massey. Furthermore, I would like to acknowledge our Practicum student, Jasmine Wall for her assistance in completing the project,
as well as the Maternity Care Coaltion and the Maternal and Child Health Working Group of the Drexel University School of Public Health for their support. Lastly, I would like to thank my
friends and family for all of their support throughout the process.
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TABLE OF CONTENTS
Abstract ..................................................................................................................................................... viii
Introduction .................................................................................................................................................. 1
Background and Significance ....................................................................................................................... 3
Importance of Prenatal Care ..................................................................................................................... 4
Disparities in Access to Care ..................................................................................................................... 6
Life Course Perspective ............................................................................................................................. 9
Prenatal Care Scale ................................................................................................................................. 10
Specific Aims ............................................................................................................................................... 11
Research Design and Methods .................................................................................................................. 12
Quantitative Methods ............................................................................................................................. 13
Qualitative Methods ............................................................................................................................... 16
Results......................................................................................................................................................... 17
Quantitative Results ................................................................................................................................ 17
Facility Type ........................................................................................................................................ 18
Available Prenatal Care Hours Weekly ............................................................................................... 19
Types of Providers ............................................................................................................................... 19
Total Number of Prenatal Care Hours by Provider Type .................................................................... 20
Full Time Equivalency (FTE) ................................................................................................................ 21
Payment Type and Insurance Coverage ............................................................................................. 23
Total Number of Prenatal Care Appointments Weekly ...................................................................... 24
Wait Time for Prenatal Care Appointment ......................................................................................... 24
Statistically Significant Differences Between Public and Private Sites ............................................... 25
Qualitative Open-Ended Questions on the Change in Prenatal Care Capacity .................................. 26
Qualitative Results .................................................................................................................................. 27
Change in Prenatal Care Capacity ....................................................................................................... 27
Barriers to Providing Prenatal Care .................................................................................................... 28
Facilitators to Providing Prenatal Care ............................................................................................... 29
Key Action Steps to Ensure All Women Receive Prenatal Care .......................................................... 30
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Discussion ................................................................................................................................................... 31
Limitations .................................................................................................................................................. 36
Conclusions ................................................................................................................................................. 37
Recommendations ..................................................................................................................................... 38
Bibliography................................................................................................................................................ 40
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LIST OF TABLES
Table 1 Facility Type Public ........................................................................................................................ 18
Table 2 Facility Type Private ...................................................................................................................... 18
Table 3 Percentage of Provider Type ......................................................................................................... 20
Table 4 Percentage of All Hours by Provider Type .................................................................................... 21
Table 5 Full Time Work Equivalency (FTE) ................................................................................................. 22
Table 6 Statistically Significant Differences Between Public and Private Sites........................................ 26
Table 7 Change in Prenatal Care Capacity ................................................................................................. 27
Table 8 Barriers to Providing Prenatal Care .............................................................................................. 28
Table 9 Facilitators to Providing Prenatal care ......................................................................................... 30
Table 10 Key Action Steps to Ensure All Women Receive Prenatal Care ................................................. 31
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LIST OF GRAPHS
Graph 1 Reported Facility Type ................................................................................................................. 18
Graph 2 Percentage of Total Providers and FTE of Provider Type............................................................ 23
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LIST OF APPENDICES
Appendix A .................................................................................................................. Quantitative Survey
Appendix B ................................................................................................ Qualitative Interview Questions
Appendix C ..................................................................................................... Informational Letter to Sites
Appendix D ............................................................................ Community Coalition Action Theory (CCAT)
Appendix E .................................................................................................... Identified Prenatal Care Sites
Appendix F ....................................................... Available Prenatal Care Hours at Public and Private Sites
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ABSTRACT
Prenatal Care Capacity Assessment in Philadelphia Rosie Ganser MPH1, Dr. Nathalie A. Bartle EdD1,
Jennifer Breaux DrPH MPH1, Deborah Roebuck2, Maria Ness MPH2
1Drexel University School of Public Health, 2Philadelphia Department of Public Health
Philadelphia has one of the highest rates of infant mortality in the nation. With the closure of 13 obstetric (OB) inpatient units since 1997, the question arises if there is sufficient prenatal care capacity in Philadelphia at this time. The objectives of this study are to: 1) determine the number of prenatal care slots available in Philadelphia; 2) determine the full-time work equivalent of providers offering prenatal care; 3) identify the available hours for prenatal care 4) determine types of insurance and/or payment methods; 5) identify the average length of time a newly pregnant woman has to wait for an initial appointment; and 6) identify how prenatal care capacity has changed in the past 5-10 years. Quantitative surveys were e-mailed and faxed to identified sites and qualitative interviews were conducted with four key personnel. Completed surveys were received from 20 sites. The calculated FTE for a total of 90 providers was 19.8 providers, which represents a workforce of only 22% of the possible 100%. The majority of available hours were reported between 8AM and 5PM, Monday-Friday, with 10% of sites providing hours before 8AM and 25% of sites providing hours after 5PM. All sites reported accepting private insurance and medical assistance. Additionally, the average wait time for a prenatal care appointment was reported to be 10.26 days. Qualitative findings were consistent with the literature. Prenatal care hours need to be expanded and the provider work-force needs to be increased. Furthermore, political and economical barriers to providing the critical support services need to be addressed and implementation of an annual city-wide surveillance for prenatal care capacity is necessary.
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Introduction
Philadelphia has one of the highest rates of infant mortality of all urban locations. As of
2008, the overall rate was 10.8 per 1,000 live births, placing Philadelphia fifth in the nation for
highest infant mortality rate (Pennsylvania Department of Health, 2009). Currently the national
infant mortality rate is 6.7 per 1,000 live births, putting the United States (U.S.) behind 46 other
developed countries (National Center for Health Statistics, CDC, 2010). One possible reason for
the high infant mortality rate is the large number of babies born pre-term (Hamilton, Martin, and
Ventura, 2011). Births that occur before 37 weeks of gestation are considered to be pre-term
(Goldberg & Dwight, 1998), and currently account for 12% of all babies born in the US
(National Center for Health Statistics, 2010).
Adequate prenatal care is considered a modifiable risk factor related to pre-term births
and is defined as:
• “The timing and initiation of care;
• Adherence to a prescribed visit schedule;
• The content of medical care, including assessment of risk status; medical tests to
scren for and diagnosis disease conditions; medical procdures for the treatment of
diseases; assessment of the need for and referral to ancillary services; provision of
health education; and so on;
• The type training and organization of provider(s) of care;
• The setting of care;
• The content of ancillary services, including educational, nutritional, and
psychosocial service; case management; tobacco, alcohol, and substance abuse
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counseling; social support intervention services; outreach and follow-up services,
and so on;
• The quality, availability, accessibility, organization, and functioning of the
prenatal care provider system, including patient/provider/system interactions
(Alexander & Kotelchuk, 2001).”
The lack of adequate prenatal care in Philadelphia, which currently lags behind other cities,
potentially impacts the high infant mortality rate (Jessop, et al. 2005; Rouse, Fantuzzo, LeBoeuf,
2011). For example, 13 hospitals have closed their inpatient obstetric (OB) units since 1997
(Bishop, 2006), and with a small increase of births from 22,753 in 1996 to 23,431 in 2009
(Pennsylvania Department of Health, 2010), there is concern that prenatal care capacity has been
dramatically affected by this increase in demand for obstetric services.
Health outcomes including the rates of low birthweight babies, preterm pregnancies,
perinatal and maternal mortalities, infant mortalities, and severe maternal morbidity are
recognized indicators of sufficient and appropriate reproductive health care (Cunningham, et al.,
Chapter 1, 2010). However, while such statistics do reflect the status of reproductive care for a
given locale, they are also influenced by a number of sociodemographic, behavioral and medical
risk factors. Thus, in assessing Philadelphia’s system of prenatal health care delivery, it is
important to keep in mind that insufficient or inappropriate prenatal care is one among many risk
factors that influence birth outcomes (Alexander, Kogan, & Nabukera, 2002).
Since the literature suggests that prenatal care is of great importance for good maternal
and infant health outcomes, it is fitting that the Maternal Child and Family Health (MCFH)
Division of the Philadelphia Department of Public Health (PDPH) sought to address these issues.
Thus it is vital to know the magnitude of capacity issues related to prenatal care in Philadelphia.
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In order to investigate these issues, the Maternal and Child Health Working Group (MCHWG)
within the Drexel University School of Public Health (DUSPH) partnered with the MCFH
division.
The primary goal of this study was to conduct an assessment to determine the extent of
prenatal care capacity, both public and private available to pregnant women in Philadelphia. This
study addressed the level of sufficiency as it relates to prenatal care within Philadelphia’s system
of reproductive health care delivery. “Prenatal care capacity” refers to the system’s ability to
meet prenatal care needs of pregnant women in terms of providing an adequate number of
appointments within an acceptable time frame for women in various trimesters of their
pregnancies according to recommendations from the American College of Obstetrics and
Gynecology (ACOG) and the current standard of care. Prenatal care capacity, or the capacity of
the provider workforce is distinct from the quality of care provided, although both contribute to
the provision of adequate prenatal care. The ability of this system to provide care that is adequate
in terms of quality will be addressed by this project in future studies.
Background and Significance
Prenatal care is a very important component of reproductive health care. The ultimate
goal of providing reproductive care, in the forms of preconception, prenatal, peripartum and
neonatal care, is to maximize the health outcomes for newborns and mothers, which in turn, are
reflected by a number of local and national perinatal statistics (Thompson, Goodman, & Little,
2002). The significance of prenatal care and the impacts of disparities in access to care, as well
as the manner in which prenatal care utilization is measured, can all impact the reported positive
health outcomes for mothers and babies. The large disparities in poor birth outcomes have been
further explained with recent studies utilizing the theory of the Life Course Perspective.
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Importance of Prenatal Care
Pregnancy outcomes have shown to improve with early preventive care beginning at
preconception (Kirkham, Harris, & Grzybowski, 2005). The standard for the timing of initiation
of prenatal care is accepted as occurring within the first trimester of pregnancy (Kirkham, Harris,
& Grzybowski, 2005). Timeliness in which care is initiated is very important and it is necessary
for a system have the capacity to initiate care in a timely manner. The Agency for Healthcare
Research and Quality (AHRQ) addressed the issue of timeliness of care in their Nataional
Healthcare Quality Report (2011). Care that is not administered in a timely manner can lead to
emotional discomfort, greater costs for treatment, and can have negative impacts on physical
health (Boudreau, et al., 2004).
The goals of the initial prenatal care visit, are to determine the health status of the mother
and fetus, estimate the gestational age, plan for and initiate continued care, and determine if any
major health risks exist according to the patient’s family and past medical history (Kirkham,
Harris, & Grzybowski, 2005; American College of Obstetrics and Gynecology (ACOG), 2004).
Because screenings and further evaluations are based on gestational age, it is important to
accurately determine the estimated delivery date (EDD) at this early prenatal care appointment.
Further prenatal appointments and a plan for subsequent care may vary from somewhat
infrequent visits for a low-risk pregnancy to prompt hospitalization if the risk to maternal or fetal
life is observable or imminent (Cunningham, et. al., 2010).
The benefits of prenatal care have been highly debated and in order to address this
debate, Villar and Bergsjo reviewed the evidence-based reasons for prenatal care (Villar &
Bergsjo, 1997). Since there is disagreement as to what the actual benefits of prenatal care are,
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they focused on the components of prenatal care which are proven to be preventive and help
reduce risk for mothers. These factors include bleeding, anemia, preeclampsia, sepsis and genito-
urinary infection and obstructed labor. An additional maternal health benefit includes detection
of gestational diabetes (Prenatal Care, 2004).
Prenatal care also provides health benefits for the baby. This includes the recognition of
genetic abnormalities, unusual fetal position or restricted growth, and fetal problems or distress
(Prenatal Care, 2004). A lack of prenatal care can lead to a higher risk of maternal morbidity and
mortality and pre-term births and low birth-weight births (Alexander & Kotelchuck, 2001,
Vintzileos, et al., 2002, Cunningham, et al., Chapter 1, 2010). Low birth-weight infants are at
higher risk for abnormal growth rates, sickness, neurodevelopmental issues, and late onset sepsis
(Hack, Klein, & Taylor, 1995; van Wassenaer, 2005; Stoll et al.,1996). They are also at a greater
risk for health issues later in life including hypertension, diabetes, psychological distress, and
obesity (Curhan et al., 1996; Wiles, Peters, Leon, & Lewis, 2005).
A study reviewing a low-income population in New York State determined there was an
association between receiving adequate prenatal care and the utilization of well-child visits
postpartum, suggesting an impact on newborn care as well (Cogan, et al., 2012). The study also
found that adequate prenatal care was associated with a child receiving a lead test by age two.
The findings from this study suggest that prenatal care is a protective factor for healthy practices
after birth, providing additional potential health benefits for the baby.
Withholding prenatal care would be deemed unethical making a randomized control trial
an impossibility to confirm the positive effects of prenatal care. However, recent studies show
that the ways in which the effectiveness of prenatal care is viewed in terms of birth outcomes
may be impractical. Dooley and Ringler (2012) suggest that prenatal care should be viewed for
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its psychosocial impacts, the improvement of the patient-provider relationship, and the ability to
provide continuous education. These impacts include the ability to provide early intervention
with high risk behaviors that include smoking, drug use, poor nutrition, and the treatment of
sexually transmitted diseases (Bennett, et al., 2006, Kirkham, Harris, & Grzybowski, 2005). The
development of this strong relationship between the pregnant woman and her health care
provider has the potential to transform into the lifelong establishment of primary and preventive
care for the mother and baby, as well as for other family members.
Coordination of care is largely important in improving health outcomes for patients. The
AHRQ listed improved communication and coordination of care as a national priority area in
their National Healthcare Quality Report (2011). Coordination of care has been shown to reduce
morbidity and mortality and to be cost effective (Shojania, et al., 2007). Developing a strong
relationship with a prenatal care provider and coordinating care for the patient have the potential
to greatly improve the experience for the patient and positively impact birth outcomes.
Disparities in Access to Care
Prenatal care is preventive care that can provide assessment and medical treatment, as
well as address psychosocial issues (Villar & Bergsjo, 1997). These psychosocial issues were
examined in a Washington, DC based study of the determinants of late prenatal care for African
American Women (Johnson, et al, 2003). Findings from the study showed that factors
influencing late prenatal care initiation included young maternal age, unemployment, no history
of abortions, current consideration of abortion, inability to pay for prenatal care, and no interest
in personal health status. Barriers to service were also reported in a study by Tossounian,
Schoendorf, Kiely (1997) as hours not being convenient and not knowing where to go.
Beckmann, Buford, & Witt (2000) address additional barriers to receiving prenatal care. These
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barriers include length of wait time at appointment and cost of transportation. Furthermore, a
study in a Midwestern community investigated the factors that contribute to late prenatal care
initiation (Roberts, et al., 1998). Findings included barriers to obtaining an initial appointment,
patient perception of prenatal care as unimportant, and unintended pregnancy. These studies
provide a significant amount of evidence displaying the overwhelming barriers that exist for
women to access prenatal care.
A Geographic Information Systems (GIS) analysis of the impacts on capacity of the
closure of the 13 hospitals in Philadelphia was addressed in a 2010 report (Cordivano, 2010).The
analysis revealed that for a healthy pregnancy, 25 visits to the provider and support services were
necessary for a total transportation cost of nearly $70. However, for a high risk pregnancy, the
total number of necessary visits to the provider and support services increased to 34 visits and a
total transportation cost of nearly $100. A measurement of the average travel distance for
Philadelphia resident patients for each remaining open OB unit in Philadelphia, also increased by
more than 15%, except at Pennsylvania Hospital. All hospitals experienced an increase in
obstetric patients with the largest being at Albert Einstein hospital with an increase of 95.68% in
births from 1996 to 2008 and the lowest being at Thomas Jefferson Hospital with an increase of
17.98%. This paints a picture of the impacts of the OB unit closures on increasing barriers for
women, most significantly high risk women, and the increase in demand based on an increase in
the number of births. Both have the potential to contribute negatively to the birth outcomes for
Philadelphia residents.
A study by Shi, et al. (2004) focused on the impact of community health centers (CHCs)
on racial and ethnic disparities in perinatal birth outcomes. The study focused on the disparities
that exist between African American infants and other racial groups that include whites,
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Hispanics, and Asians. At the time of the study in 2004, the rates of infant mortality and low
birth-weight babies were higher for African Americans babies with a rate of 13.5 per 1,000 live
births and 13.3% respectively (Arias, et al., 2003). Rates for infant mortality in whites,
Hispanics, and Asians were 5.7 per 1,000 live births, 5.4 per 1,000 live births, and 4.7 per 1,000
live births. Rates for low birth-weight babies in whites and Hispanics were 6.9% and 6.5%.
Notable findings in the study found that CHCs with an increased capacity for prenatal care had
higher rates of first trimester prenatal care initiation and were affiliated with a decreased low
birth weight rate. It was suggested that while this finding does not imply causality, it may be
heavily influenced by the manner in which CHCs promote access to prenatal care. This
association suggests that because CHCs serve higher risk populations, increasing capacity and
first trimester prenatal care initiation may lead to a decrease in adverse perinatal outcomes.
Provider capacity has the potential to serve as a barrier and negatively impact health
outcomes (Donabedian, 1980). AHRQ explored the concept of a workforce shortage and the
impact that this has on health outcomes. The National Healthcare Quality Report (2011) reported
that the Health Resources and Services Administration (HRSA) has estimated that the shortage
of physicians will be as large as 100,000 providers and 1 million nurses. A woman’s perceived
health risk and health literacy also play a large role as a barrier to accessing prenatal care.
Headley and Harrigan (2009) suggest that women who do not identify as high risk may not fully
understand the importance of prenatal care. Infrastructure barriers such as low provider capacity
and long wait times, intersect with personal barriers, such as lack of access to transportation,
inability to pay, and perceived risk, and high risk behaviors, such as smoking, poor nutrition, and
drug use, to exacerbate poor birth outcomes.
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Life Course Perspective
Social determinants of health and the impacts across the life-span are critical to consider
in prenatal care research. The Life Course Perspective, a framework by Lu and Halfon (2003),
addresses the disparities that exist among women in biological, environmental, psychological,
behavioral and social protective and risk factors. Focus is placed on stressors experienced in
critical development periods such as in utero and the summative impact known as weathering
later in life. Principles from the life course perspective provide strong evidence for the
importance of prenatal care for later health outcomes for the baby.
Additionally, the Life Course Perspective attempts to address why the disparities in birth
outcomes exist among different racial groups, most notably African Americans and whites. As of
2006, the CDC reported the disparity to be as large as 13.3 infant deaths per 1,000 live births for
African Americans and 5.6 infant deaths per 1,000 live births for whites (CDC, 2008). As of
2010, the infant mortality rate in Philadelphia was on par with the national infant mortality rate
for African Americans with a rate of 13.2 deaths per 1,000 live births (Pennsylvania Department
of Health, 2010). While the infant mortality rate in Philadelphia for whites is much higher than
the national rate at 10.5 per 1,000 live births as of 2010, a disparity in the rates between whites
and African Americans still exists.
The leading causes of mortality among African American infants were low-birth weight,
congenital malformations, and sudden infant death syndrome (SIDS). Moreover, women who are
at a greater risk are also not as likely to initiate prenatal care as women who are of lesser risk
(Kogan, et al., 1998, Markovitz, et al., 2005). Through the Life Course Perspective, it is argued
that African Americans are exposed to greater risks and fewer protective factors throughout their
lifespan and this contributes greatly to the disparity in infant mortality and poor birth outcomes
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(Lu & Chen, 2004). These risks are characterized as stressors and they include emotional,
economical, partner-motivated, and traumatic stressors.
Prenatal Care Scale
How prenatal care is measured can greatly impact the results of the positive effects of
prenatal care. In 1994, Kotelchuck developed the adequacy of prenatal care utilization index
(APNCU), which divided pregnancy into two rather than three-month intervals, allowing for
greater precision and the addition of an adequate-plus category to measure the ratio of observed
to expected prenatal care visits (Kotelchuck, 1994). The APNCU is now considered the standard,
as reflected by the fact that it was the only index used in the National Center for Health
Statistic’s 2004 natality files, which is a report for the current vital statistics systems data
reported by the Centers for Disease Control (VanderWeele et al, 2008). The APCNU measures
prenatal care through two levels: Adequacy of Initiation of Prenatal Care and Adequacy of
Received Services. It is worth noting that, depending on the index used, there is a great deal of
variation in the number of cases assigned to a particular category of care (VanderWeele et al,
2008), resulting in disagreement about the conclusions drawn regarding the association of
prenatal care with poor birth outcomes. By first assessing the capacity to provide care and later
assessing the quality of care provided, this study’s design aims to avoid some of these
complications.
An editorial published by Nicolaides in 2011 suggests a modification to the traditional
prenatal care model as presented by the APCNU. It would include an assessment at 11-13 weeks
of gestation to focus more in individualized care related to disease risk rather than a set number
of visits for everyone (Nicolaides, 2011). An estimation would be made at the 11-13 week visit
on the potential risk for disease. Most women would be considered low-risk and their number of
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appointments would be reduced. While reducing the number of prenatal care appointments for
high-risk women is certainly not a suggestion, it is a potential solution for women who are of
low-risk. This model of care can provide a potential framework for a future prenatal care
utilization index that is different from the current APCNU. Both the APCNU and the suggested
modified model by Nicolaides stress the importance of prenatal care initiation in order to reach
adequate prenatal care utilization throughout the duration of a pregnancy (Anderson &
Kotelchuck, 2001).
Specific Aims
A complete assessment of prenatal care capacity for pregnant women in Philadelphia will
be addressed in this study by the following:
1. Assessment of the number of prenatal care slots available in Philadelphia via
examination of providers by type -- obstetrician/gynecologist (OB/GYN), general
practitioner (GP), physician assistant (PA), nurse practitioner (NP), mid-wife, or
resident -- including name of institution and address and phone number of where care
is delivered
2. Examination of the full-time work equivalent (FTE) at sites of providers offering
prenatal care
3. Examination of the available hours at various sites designated for prenatal care
4. Examination of insurance and/or payment methods (Medical Assistance, Private, Self-
pay, Uninsurable patients, Uninsured patients, and “Other”) that providers accept for
prenatal care
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5. Elaboration on the average length of time a newly pregnant woman has to wait for an
initial appointment, including an examination of minimum and maximum times at the
individual sites
6. Summations regarding changes in site prenatal care capacity in the past 5-10 years?
Research Design and Methods
This study utilized a mixed methods design to determine the degree to which there is an
affiliation between prenatal care capacity and type of site. This study aimed to determine what
the capacity to provide care is and if there is a difference of prenatal care capacity between
private and public sites. This was done by using a mixed methods approach through an online
quantitative questionnaire and conducting qualitative interviews. A mixed methods approach
strengthens the study by allowing for corroboration of results between the different research
methods through triangulation and by enhancing, illustrating, and clarifying the results through
complementarity between the quantitative surveys with the results from the qualitative
interviews.
The Community Coalition Action Theory (CCAT) was used as a theoretical framework
for this study (Glanz, Rimer, Viswanath, 2008). The CCAT uses interorganizational relationship
theory to build relationships in the community and develop collaborative organizational
relationships. Additionally, CCAT incorporates Stage Theory, which determines how coalitions
move through the process from formation and implementation to maintenance and
institutionalization. The theory also allows for the consideration of community aspects including
sociopolitical climate, geography, history, and norms (See Appendix D for a visual of the CCAT
model). The MCFH division of the PDPH and the MCHWG of DUSPH came together to
collaborate on a study informed by the recognized issues of high infant mortality and low
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prenatal care utilization rates in Philadelphia. Currently, both organizations are working to assess
the actual prenatal care capacity in the city of Philadelphia, a suggested contributor to these poor
birth outcomes. Once a comprehensive study has been completed, DUSPH plans to report the
findings to the PDPH and form policy recommendations to be considered for broader city level
policy change. The goal is to translate this research into policy change that leads to an
improvement in prenatal care capacity and health outcomes for pregnant women in Philadelphia.
Quantitative Methods
Prenatal care provider and site listings were previously directly obtained from managed
care organizations for a pilot study conducted in 2011. These did not include listings obtained
from commercial insurance website directories that were utilized in this study. A query of online
commercial insurance databases of the five most popular insurance plans in Philadelphia was
conducted in order to obtain commercial insurance prenatal care provider listings. A total of
7,925 listings were acquired, which includes several duplicate listings of individual sites that
provide prenatal care. The pilot study conducted in 2011 aimed to answer the same research
questions proposed in this study but resulted in barriers to follow-up with the participants in the
study due to restrictions on information collection. In the study investigators identified the
prenatal care facilities and who provides prenatal care at these facilities. The Maternal Child and
Family Health Division assisted in determining the active prenatal care physical faciltiies.
The software program Microsoft Excel was used to sort the 7,925 total listings for unique
(first occurrence in the Excel list) and duplicate listings (repeat occurrences in the Excel list).
The list was then sorted by address and cross-checked for phone numbers since listings provided
may have multiple phone numbers provided for one physical site. All unique listings were called
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to determine if the information listed was correct and if they provided prenatal care. After
verifying the site information, sites were then asked to participate in the study.
Inclusion was based on criteria developed by investigators including: being a major
delivery hospitals’ prenatal unit in Philadelphia, an unaffiliated OB/GYN providing prenatal
care, other hospital that still provides prenatal care (but not OB), midwife, family practice unit,
federally qualified health center or a PDPH ambulatory health center. The subjects in this study
included the "point person" at the designated sites who completed the online quantiative survey
on prenatal care capacity. Inclusion for the qualitiative component was determined by recruiting
key personnel at one publicly funded health center, two hospital clinics, and two city health
centers. Criteria for the point person was someone who was an employed professional at the
prenatal care site and who was responsible for scheduling appointments or was familiar with the
procedure for scheduling.
Initially, a phone call was made to each site to explain the study. During the phone call
the researcher identified herself, the purpose of the study, and offered to answer any further
questions if necessary. Contact information for the principal investigator (PI) and co-principal
investigator (Co-PI) and a written letter of explanation of the study were provided upon request
(See Appendix C for a copy of the informational letter). Co-investigators requested the site to
identify a contact person that researchers may speak with to conduct a survey about prenatal care
capacity. The name and contact information were collected for this person and an e-mail address
was obtained. The link to the survey was sent to the identified contact person at the site through
e-mail. Follow-up phone calls and e-mails were sent to the subject if the survey was not
completed during the data collection phase. If the research subjects requested it, a hard copy of
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the survey was faxed or mailed to the site and returned to the co-investigators at Drexel
University School of Public Health (DUSPH).
Subjects were asked to complete a survey that was developed with the online survey
software Survey Monkey (See Appendix A for a copy of the Survey Monkey questionnaire). The
survey was slightly modified from the version used in the pilot study and was developed in
collaboration with the MCFH division of the PDPH and the MCC. If any participant was unable
to complete any part of the survey for which he/she was eligible, the investigators worked with
MCFH/DUSPH staff to ensure the participant had an opportunity to complete the survey at
another time that was mutually acceptable to both the participant and MCFH/DUSPH staff.
Data were downloaded into Microsoft Excel files from the Survey Monkey responses.
After reviewing the data to correct errors in reporting and missing repsonses, SPSS Statistics and
Microsoft Excel were used to analyze the data. A data analysis plan was developed in
collaboration with the MCFH division of the PDPH to include a chi-square cross-tabular analysis
to determine significant difference of the specific aims in public versus private sites. Full time
equivalency (FTE) was calculated by dividing the reported total number of prenatal care hours
available each week across all provider types by the product of the total number of providers and
the typical number of hours in a work week, or for the purpose of this study, 40 hours. This
resulted in the percentage of total providers and was then further multiplied by the total number
of providers to determine the total workforce. FTE represents the total number of full time
providers available in the work force or the total percentage of hours worked of a possible 100%
of hours for a full-time work week. For example, 90 providers with an FTE of 19.8 providers
represents 90 providers only working the full time work equivalency of 19.8 providers or only
22% of the possible 100% full time hours.
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Qualitative Methods
In addition to the quntitative study, the researcher contacted four key personnel to
complete a qualitative interview. Qualitative interviewees were identified by the research team.
The participants included two OB unit chairs at Philadelphia hospitals, one nurse-practitioner
employed by a public health center, and one certified nurse midwife employed by both a
Philadelphia hospital and a public health center. The interview was recorded and transcribed and
a theme analysis was conducted. Researchers determined an appropriate theme analysis to
incorporate the contribution of the qualitiative interview into the overall report and
recommendations (See Appendix B for the list of open-ended qustions included in the interview).
This theme analysis included a review for common themes and statements that stood out. The
frequency and average at which these common themes appeared was measured and reported
Three members of the research team conducted the theme analysis.
An Expedited protocol application was submitted to the Institutional Review Board (IRB)
at Drexel University. In addition, an application for a waiver of consent was included. After
review, the application and waiver of consent were approved. An additional IRB application was
submitted to the Philadelphia Department of Public Health (PDPH) for review near the end of
the data collection process. The additional IRB application was submitted for consideration of
the data collected from city health centers only. The IRB submitted to the PDPH was approved
before completion of this paper but limitations on data collection dramatically impacted our
ability to collect data from the city health centers during the data collection phase.
This research involved minimal risk to the subjects because no personal health
information was collected from the individual completing the survey. Only public information
was collected on the services provided by the site. All participants were given the option to
17
participate in the study. Participation was completely voluntary. All information collected was in
regards to public information about the site and did not harm the rights and welfare of the
subjects completing the survey.
There were multiple anticipated benefits as discussed in the background information
section. This information may contribute to scientific literature, positively effect the broader
society, and bring further awareness and understanding to prenatal care capacity in large urban
areas. This study may also serve as a model for other large cities to assess their prenatal care
capacity.
Results
Quantitative Results
Quantitative data variables were determined under the guidance of the MCFH Division of
the PDPH after downloading the data from Survey Monkey into Excel. The Excel data output
was cleaned up to reflect uniformed answers for data analysis. For example, in the data output, a
selection of “Aetna Better Health” as a choice under the types of Medical Assistance accepted
was coded to reflect a dichotomous variable of yes or no.
These data were then further analyzed for frequency and mean. Mean was chosen as the
method of analysis in order to fully reflect 100% of the participant reponses. For purposes of this
study, it was more appropriate than median because it was critical to include the outliers. For
example, the longest and shortest wait times for a prenatal care appointment. By using the mean,
weight was given to the outliers or those who have a disparity in access because of their long
wait times.
After sorting for duplicates in the database, it was determined that 64 sites provide
prenatal care in the city of Philadelphia (See Appendix E for the list of the identified prenatal
18
care sites). Of the 64 sites, 36 sites provided their contact information including an e-mail
address or fax number where the link to the survey was sent. A total of 22 surveys were started
and 20 surveys were completed.
Facility Type
Table 1 Public Facility Type (N=9)
Number of Sites Percentage of Total Number of Sites
City Funded Health Center
2 10%
Federally Qualified Health Center
6 30%
No Response 1 5% Table 2 Private Facility Type (N=11)
Number of Sites Percentage of Total Number of Sites
Hospital Owned 8 40% Nurse Owned 1 5% Univsersity Owned 2 10%
Graph 1
10%
30%
5%
40%
5% 10%
0%10%20%30%40%50%60%70%80%90%
100%
City-FundedHealth Center
FederallyQualified Health
Center
No Response Hospital-Owned Nurse-Owned UniversityOwned
Perc
enta
ge o
f Site
s
Reported Facility Type
Public Sites Private Sites
19
A total of 55% of the sites (N=11) were private and identified as hospital owned, nurse
owned or university owned. Additionally, 45% of the sites (N=9) were public and identified as
city funded health center or federally qualified health center.
Available Prenatal Care Hours Weekly Across Sites
The total number of available prenatal care hours weekly for public sites range from a
minimum of 4 hours to a maximum of 42.5 hours. The earliest available appointment for a public
facility was offered at 7:30 am and the latest available appointment was offered at 5:00pm (See
Appendix F for the available prenatal care hours provided by public and private participant
sites). The total number of available prenatal care hours weekly for private sites range from a
minimum of 23 hours and a maximum of 45 hours. Ten percent (N=10) of the sites provided
hours before 8:00 am and 25% (N=5) of the sites offered hours after 5:00pm. Only one of the
sites offering hours outside of the Monday-Friday 8:00am-5:00pm time interval (only before
8:00am) was a public facility and five of the sites were private. These extended hours were only
offered on Monday, Tuesday, and Wednesday.
Types of Providers
Across all sites, there was a total of 90 practitioners reported providing care (N=90). The
total number of practitioners reported at public facilities was 20. A total of two general
pracitioners, three OB/GYNs, one physician assistant, three nurse practitioners, eight midwives,
and three family medicine physicians were reported as providing care at public sites. The total
number of practitioners reported at private facilites was 70. A total of 37 OB/GYNs, two
physician assistants, 11 nurse practitioners, five midwives, 14 residents, and one perinatologist
were reported as provdiing prenatal care athe the private facilities. Across all sites, 45% of the
total number of practitioners (N=40) were OB/GYNs, 16% (N=14) were nurse practitioners,
20
16% (N=14) were residents, 14% (N=13) were midwives, 3% (N=3) were physician assistants,
3% (N=3) were family medicine physicians, 2% (N=2) were general pracititoners, and 1% (N=1)
were perinatologists.
Table 3 Public
Facility (N=9)
Private Facility (N=11)
Practitioner Type
Number of Providers
Percentage of Total Number of Providers
Number of Providers
Percentage of Total Number of Providers
Total Percentage Across All Sites
OB/GYNs 3 3% 37 42% 45% Nurse Practitioners
3 3% 11 13% 16%
Residents 0 0% 14 16% 16% Midwives 8 9% 5 5% 14% Physician Assistants
1 1% 2 2% 3%
Family Medicine Physicians
3 3% 0 0% 3%
General Practitioners
2 2% 0 0% 2%
Perinatologists 0 0% 1 1% 1% Total 20 21% 70 79% 100%
Total Number of Hours by Provider Type
Among the public site participants, general pracititoners reported providing a total of 14
hours per week for prenatal care. OB/GYNs provided a total of 40 hours weekly, physician
assistants provided a total of 40 hours, nurse practitioners provided 60 hours, midwives provided
16.25 hours, and family medicine physicians provided 11 hours of prenatal care. Among the
private site participants, OB/GYNs provided 322 hours of prenatal care weekly, physician
assistants provided 42 hours, nurse practitioners provided 154 hours, midwives provided 47
hours, residents provided 27 hours, and perinatologists provided 24 hours. Across all sites,
general pracitioners provided 2% of the total prenatal care hours weekly, OB/GYNs provided
21
46% of the hours, physician assistants provided 10% of the hours, nurse practitioners provided
27% of the hours, midwives provided 8% of the hours, family medicine physicians provided 1%
of the hours and perinatologists provided 2% of the hours.
Table 4 Public
(N=9) Private
(N=11)
Provider Type Number of Hours
Percentage of Hours of All Providers
Number of Hours
Percentage of Hours of All Providers
Total Percentage of Prenatal Care Hours Weekly Across All Sites
OB/GYNs 40 5% 322 41% 46% Nurse Practitioners
60 8% 154 19% 27%
Residents 0 0% 27 3% 3% Midwives 16.25 2% 47 6% 8% Physician Assistants
40 5% 42 5% 10%
Family Medicine Physicians
24 3% 0 0% 3%
General Practitioners
14 2% 0 0% 2%
Perinatologists 0 0% 11 1% 1% Total 194.25 25% 603 75% 100%
Full Time Equivalency
Full time equivalency (FTE) for all provider types across all sites is 19.8 or 22%. A total
of 90 practitioners provide a total workforce equivalent to only 19.8 practitioners or only 22%.
FTE for all provider types across public sites is 4.8 or 24%. A total of 20 practitioners at public
sites provide a total workforce equivalent to only 4.8 or 24%. FTE for all provider types across
private sites is 15.4 or 22%. A total of 70 practitioners at private sites provide a total workforce
equivalent to only 15.4 or 22%.
FTE was also calculated for each type of practitioner among all sites and for each public
and private sites. The total OB/GYN FTE across all sites was 9.2 or 23%, for nurse practitioners
22
it was 5.32 or 38%, for residents it was .7 or 5%, for midwives it was 1.56 or 12%, for physician
assistants is was 2.04 or 68%, for family medicine physicians it was .6 or 20%, for general
practitioners it was .36 or 18% and for perinatologists it was .28 or 28%.
Table 5 Public
(N=9) Private
(N=11)
Provider Type FTE Percentage FTE Percentage Total FTE Across All Sites
Total Percentage Across All Sites
OB/GYNs 1 33% 8.14 22% 9.2 23% Nurse Practitioners
1.5 5% 3.85 35% 5.32 38%
Residents 0 0% .7 5% .7 5% Midwives .4 5% 1.2 24% 1.56 12% Physician Assistants
1 100% 1.06 53% 2.04 68%
Family Medicine Physicians
.6 20% 0 0% .6 20%
General Practitioners
.36 18% 0 0% .36 18%
Perinatologists 0 0% .28 28% .28 28%
23
Graph 2
Payment Type and Insurance Coverage
All public and private or 100% of the sites reported accepting private insurance as well as
medical assistance coverage. Ninety-five percent of sites reported accepting self-payment, 40%
of sites reported accepting uninsured patients, and 35% of sites reported accepting uninsurable
patients. All 11 or 100% of the private sites accept self-payment from patients and eight of the
nine or 89% of the public sites accept self-payment. Eight of the nine public sites or 89% accept
uninsured patients and seven of the nine public sites or 78% accept uninsurable patients at their
sites. Zero of the private sites reported accpeting uninsured or uninsurable patients.
Respondents were asked to provide ways in which they cover uninsured or uninsurable
patients. Twenty-five percent of sites reported covering uninsured patients by signing them up
for Medical Assistance and 15% offered uninsured patients a sliding fee scale. Addtionally, 15%
2%
45%
3% 16% 14% 16%
1% 3%
18% 23%
68%
38%
12% 5%
28% 20%
0%10%20%30%40%50%60%70%80%90%
100%
Perc
enta
ge
Provider Type
Percentage of Total Providers and FTE of Provider Type
Percentage of Total Providers AcrossAll Sites
FTE of Provider Type
24
of sites offer uninsurable patients a sliding fee scale and 10% of sites refer them to city health
centers.
Total Number of Prenatal Care Appointments Weekly
Across all 20 sites, a total of 918 available prenatal care appointments weekly were
reported. Of those 918 appointments, 138, or 15%, were available for new prenatal care patients.
Public sites reported providing a total of 282 prenatal care appointments weekly and of those 282
appointments, 55 or 20% were available for new prenatal care patients. Private sites reported
providing 636 prenatal care appointments weekly and of those 636 appointments, 83 or 13%
were available for new prenatal care patients.
Wait Time for Prenatal Care Appointment
Wait time at sites was calculated by determining the number of days between the date of
the reported available appointment and the date the survey was completed. The average reported
wait time for a prenatal care appointment across all sites was 10.26 days with a maximum wait
time of 32 days and a minimum wait time of 1 day. Public sites reported an average wait time of
9.1 days with a maximum of 22 days a minimum of 1 day. Private sites reported an average wait
time of 10.27 days with a maximum of 32 days and a minimum of 1 day.
Across all sites, the average wait time for an intial prenatal care appointment for a
medically high risk patient was 5.69 days, for a patient with prior pregnancy complications it
was 6.25 days, for a first trimester patient it was 11 days, for a second trimester patient it was
8.11 days, and for a third trimester patient it was 7.11 days. Among public sites the average wait
time for an intial prenatal care appointment for a medically high risk patient was 5.56 days, for a
patient with prior pregnancy complications it was 5.56 days, for a first trimester patient it was 9
days, for a second trimester patient it was 6.56 days, and for a third trimester patient it was 6.56
25
days. Among private sites the the average wait time for an intial prenatal care appointment for a
medically high risk patient was 3.73 days, for a patient with prior pregnancy complications it
was 4.55 days, for a first trimester patient it was 11.64 days, for a second trimester patient it was
8.64 days, and for a third trimester patient it was 6.27 days.
Statistically Significant Differences Between Public and Private Sites
SPSS Statistics Software was used to test for a significant difference between public and
privates sites using Pearson Chi Square for the following items:
• Total number of prenatal care hours
• Total number of practitioners
• Total number of practitioners by type
• Accepting private insurance or medical assistance
• Percentage of patients using each type of insurance
• Accepting uninsured or uninsurable patients
• The percentage of patients that are uninsured or uninsurable among sites that do accept
them
• Total number of prenatal care appointments weekly
• Currently accepting new patients
• Total number of new prenatal care appointments available for new prenatal care patients
weekly
• Wait time for a prenatal care appointment in days
• Wait time for an initial prenatal care appointment in days for a medically high risk
patients, a patient with prior pregnancy complications, a 1st trimester patients, a 2nd
trimester patient, and a 3rd trimester patient
26
Because of the small sample size, consideration was given to using a significance level of
0.1. However, all significant items at the 0.1 level were also significant at the 0.05 level.
Table 6 Characteristic of Site Private Site Public Site Significance of
Difference Percentage Accepting Uninsured Patients
0%* 88% p< 0.001
Percentage Accepting Uninsurable Patients
0%* 78% p< 0.001
Average Wait Time in Days for 2nd Trimester Patients
8.64 days 6.56 days p= 0.04
*Qualitative interview respondents reported accepting uninsured and uninsurable patients at their private sites. However, this was not reflected in the quantitative survey results. The reported private sites that accept uninsured and uninsurable patients did not participate in the online survey.
Quantitative Open-ended Questions Assessing How Prenatal Care Capacity Has Changed at
the Site in the Last Five to Ten years
Quantitative participants were asked to report on how prenatal care capacity has changed
at their site in the last five to ten years. Thirty-five percent of respondents reported that change
was unknown or there was no change in the last five years and 50% of respondents reported the
same findings for change in the last ten years. These results were consistent with themes found in
the qualitative interviews in regards to the increase in prenatal care capacity by increasing the
number of providers and growth in the program. There was also corroboration in the finding of
an increase in demand for appointments at the sites. The open-ended responses also revealed a
significant finding with 15% of respondents reporting an increase in the number of prenatal care
appointments in the last five years.
27
Qualitative Results
Qualitative interviews were transcribed and separated by the research questions that were
asked. The transcriptions were hand-coded by the student researcher, principal investigator, and
a co-investigator on the project. Common themes in response to each specific question were
determined along with responses that stood out. The frequency and average at which these
common themes appeared was measured and reported. A total of four people participated in the
qualitative interviews. The participants consisted of two OB chairs employed at Philadelphia
area hospitals, one CRNP employed at a publicly funded health center, and one CNM employed
at both an area Philadelphia hospital and a publicly funded health center.
Change in Prenatal Care Capacity in the Last 5-10 Years
Respondents were asked how prenatal care capacity has changed at their site in the last
five to ten years. A total of 75% of the respondents reported that prenatal care capacity had
increased at their site in the last five to ten years. A number of factors contributed to these
increases. For example, 50% of sites reported making facility and systems changes and 50% also
reported increasing the number of providers at their site. Additionally, 25% of the sites reported
providing the option to go to other affiliated sites and increasing commercial insurance volume.
Table 7 Change in Prenatal Care Capacity Percentage of Respondents Reporting This
Type of Change Increased 75% Facility and system changes 50% Hired additional providers 50%
Evidence of an increase in prenatal care capacity was recorded in the interviews. Most
notably, one participant stated “You’re talking to someone that has expanded prenatal care
because I opened the doors for undocumented and uninsured women… I just do it because I
28
think it is the right thing.” – OB Chair, Philadelphia Hospital. Another respondent stated “I think
our site, because it’s a public funded city clinic, it’s busier than ever.” – CRNP, Publicly Funded
Health Center.
Barriers to Providing Prenatal Care at Their Site
Respondents were asked what the barriers are to providing prenatal care at their sites. All
respondents, 100%, reported that social support and educational needs of patients were a
significant barrier to providing prenatal care to patients. Furthermore, 75% of respondents
reported prior existing health issues as a barrier to providing prenatal care for their patients at
their sites. A limited understanding of importance of prenatal care was reported by 50% of the
respondents as a barrier to providing prenatal care, as well as ambivalency towards the
pregnancy, a short length of time for an appointment, and obstacles in initiating care. Obstacles
in getting the first appointment were reported as a barrier by 50% of the repsondents due to
policies that require patients to come in for an intial screening appointment days before the initial
prenatal care appointment. Fifty-percent of the respondents reported that policies that have been
proven to be successful are not regularly adopted by the city health centers.
Table 8 Barriers to Providing Prenatal Care Percentage of Sites Reporting This Type of
Barrier at Their Site Social support and educational needs of patients
100%
Prior existing health issues 75% Limited understanding of importance of prenatal care
50%
Ambivalent toward pregnancy 50% Obstacles in initiating care 50%
Twenty-five percent of respondents reported additional barriers to providing prenatal care
at their sites. These barriers included not receiving primary care, not having additional ancillary
29
services such as nutritionists and social workers, a long wait time to get an intial appointment
because of high patient volume, lack of insurance, real economic issues, transportation access,
and resident providers having a high workload.
Many of the reported barriers to prenatal care were supported by notable quotes from the
respondents. More specifically, one respondent stated that “There’s a long trail that you have to
go down to actually get a first OB appointment.” – CNM, Philadelphia Hospital and City Health
Center. One respondent spoke to the barriers as a result of the small window of operating hours
for certain departments. “ Everyone goes to lunch for an hour and you really have a small
window of time to provide care to sometimes 60-65 patients.” – CNM, Philadelphia Hospital and
Publicaly Funded Health Center
One respondent had an alternative view than the other respondents. They were quoted
saying “There are many barriers on the patient side, not on our side… They have psychiatric
issues… drug addiction issues. Support is very limited.” – OB Chair, Philadelphia Hospital.
Facilitators to Providing Prenatal Care at Their Site
Respondents were asked what were the facilitators to providing prenatal care at their site.
A total of 75% of the respondents reported collaboration among the six hospitals providing
obstetrical care to come up with quality care measures. Twenty-five percent of sites also reported
competency and continuity of prenatal care providers and staff as a facilitator. One unique
response by one repsondent was that their Philadelphia area hospital was able to provide
undocumented citizens with ultrasounds and prenatal care at not cost to the patients through a
contract they had with the city.
30
Table 9 Facilitators to Providing Prenatal Care Percentage of Respondents Reporting This
Type of Facilitator at Their Site Six OB Hospitals Collaborating 75% Provider Competency 25% Continuity of Providers 25% Philanthropy 50%
One respondent was quoted saying The six hospitals that are still providing delivery
services have collaborated to come up with quality care measures, and the six chairmen get
together on a every two or three month basis to identify problems and try to work together. – OB
Chair, Philadelphia Hospital. One respondent also reported a low no-show rate as a facilitator to
care stating “I will tell you that the patients who see the midwives primarily at the women’s care
center have less no shows than patients who see the residents.” – CNM, Philadelphia Hospital
and Publicaly Funded Health Center
Key Action Steps to Ensure All Women Receive Prenatal Care
Respondents were asked what three key action steps they felt would ensure all women
receive prenatal care in Philadelphia. Fifty-percent of the respondents reported placing
importance on prenatal care for the patients as an action step. A total of 50% of the respondents
also reported the need to create a shared electronic medical record. Additional responses also
included increasing the number of providers (25%), better shared information source between
support agencies (25%), prenatal care as a universal right for all women (25%), educating
everyone (25%), academic medical centers using the DHHS guide to community engagment to
improver relationship with the community (25%), and having more people with passion and
heart enter the field (25%).
31
Table 10 Key Action Steps to Provide Care Percentage of Respondents Recommending
Implementation of This Key Action Step Place importance on prenatal care 50% Shared electronic medical record (EMR) 50% Shared information source among all support services
25%
Community engagement by academic medical centers
25%
One notable response by a participants was “But the patients who need it most are the
ones that don’t tend to access it. Those patients who don’t have regular primary care, who have
multiple health issues, and obesity, and things that we now know place your pregnancy at risk.
Those are the patients that are not accessing, those with substance abuse issues.” – CNM,
Philadelphia Hospital and City Health Center. Another unique response was a suggestion by a
respondent that stated “I would love to see maternal and child health medical homes for all the
supportive, educational, and medical services.” – CRNP, Publicly Funded Health Center.
Discussion
The inadequate provider workforce with an FTE of only 22% could be the result of a
number of factors. The inclusion of all types of providers potentially skews this result providing
a somewhat inaccurate picture of the actual provider workforce in Philadelphia. However, the
OB/GYN provider type alone represents 45% of the total reported number of providers and 46%
of the total number of hours provided, yet this group reported one of the lowest FTEs at 23%. In
order to expand the provider workforce in Philadelphia, it is important to consider the use of
other licensed providers such as nurse practitioners and physician assistants, who represented
much more significant FTEs at 38% and 68%. Dooley and Ringler (2012) suggested that prenatal
care should be viewed for its psychosocial impacts, the improvement of the patient-provider
relationship, and the ability to provide continuous education. A consistent provider workforce
32
with providers who offer prenatal care hours full-time creates a plan of care that includes
continuous education, the establishment of a strong patient-provider relationship, and the ability
to result in positive psychosocial impacts.
A low number of average appointments available per day were reported across all site
participants. With the high patient volume at more than 23,000 births annually and only 64 sites
providing prenatal care, there is a possibility that sites are not providing an adequate number of
appointments daily or weekly for women receiving prenatal care in Philadelphia. There are few
studies that address prenatal care capacity, which calls for further research on this issue.
However, a study by Shi, et al. (2004) found that an increased capacity for prenatal care at
Community Health Centers (CHCs) lead to higher rates of first trimester prenatal care initiation
and was affiliated with a decrease in the rate of low birth weight babies. It was suggested that
while this finding does not imply causality, it may be heavily influenced by the manner in which
CHCs promote access to prenatal care through increased capacity. This association suggests that
because CHCs serve higher risk populations, increasing capacity and first trimester prenatal care
initiation may lead to a decrease in adverse perinatal outcomes.
Partnerships founded in the Community Coalition Action Theory between professional
programs, such as nurse practitioner programs and physician assistant programs, and the city,
state, or local level government provide an opportunity to increase the number of these types of
physicians as prenatal care providers. Programs that utilize incentives such as loan forgiveness
would provide additional resources for these types of providers and remove the barriers to
education and licensure. These types of innovative initiatives are critical in improving the poor
birth outcomes of Philadelphia and provide a means to address the projected shortage of
physicians and nurses as reported in the National Healthcare Quality Report (2011).
33
Additional consideration needs to be given to address the qualitative findings that
coordination of clinical care and support services and initiation of prenatal care are significant
barriers to adequate prenatal care. The National Healthcare Quality Report (2011) reported this
to be a means to improve health outcomes for patients and increase cost-effectiveness (Shojania,
et al., 2007). In order to address this, it is necessary to consider alternative approaches to
managing the psychosocial and prenatal care needs of pregnant women in Philadelphia. Birth
doulas are trained community health workers who provide emotional, informational, and
physical support for pregnant and laboring women throughout the birthing process (Kane Low,
Moffat, & Brennan, 2006). Additionally, the impacts of doulas reach beyond the biological
elements. Utilizing doulas as coordinators between clinical care needs and psychosocial support
needs, essentially turning them into patient navigators referred to as “psychological doulas,”
provides the opportunity to reduce life stressors that negatively impact birth outcomes such as
preterm birth.
A lack of education on the importance of prenatal care and the perception that care is not
important were found in both the qualitative findings and the review of literature. In order to
address this it is important to increase awareness of the importance of prenatal care through a
public education campaign. This can be done during the “Implementation of Strategies” stage of
the CCAT. Partnerships with schools utilizing community health workers such as birth doulas
can provide the necessary training and resources to provide education on the importance of
prenatal care to young women before they are pregnant in the preconception stage (Kirkham,
Harris, & Grzybowski, 2005).
The literature also revealed that initiation of care was a considerable barrier to prenatal
care utilization. This was consistent with the qualitative findings that the process of having to
34
attend a pre-screening appointment before the actual initial prenatal care appointment creates an
extra burden on pregnant women. One significant finding from this study was that there is no
known comprehensive list of identified prenatal care sites published and available to pregnant
women. To counter the lack of information available about sites that provide prenatal care and
help alleviate the burden of initiating care, it seems it is important for the Maternal Child and
Family Health Division of the Philadelphia Department of Public Health to distribute widely
resource lists in multiple formats (e.g. print, interactive webpage, etc.) for diverse populations,
with the goal of providing correct listings of prenatal care sites. This resource list would be
distributed to multiple referral services (e.g. social service agencies, primary care providers,
etc.).
The qualitative findings revealed that the complicated process to iniating care created
additional barriers for women to initiate care. This was supported in the literature through a study
by Beckmann, Buford, & Witt (2000). While the quantitative finding that there is an average
wait time across all sites of 10.26 days also suggests that the high patient volume and demand
could be impacting this wait time, the finding that private sites have a maximum wait time of 32
days and private sites have a maximum wait time of 28 days is more significant and accounts for
the outliers who experience disparities in access through long wait times at these sites. One
possible explanation is that it could also be impacted by the difference in policies for scheduling
different types of patients (e.g. first trimester vs. second trimester). However, with the
knowledge that the timeliness of care can negatively impact health outcomes, it is important to
address this discrepency by streamlining the process to obtain an initial prenatal care
appointment and standardize the policies for scheduling across all institutions.
35
The quantitative results also revealed that hours outside of the 8:00am-5:00pm work day
were very limted. This could highly impact working mothers without vacation time, sick leave,
or maternity leave benefits, or women who access other support services that are only open
between 8am-5pm, such as the Welfare Department. Inconvenient hours and long wait times
were reported in the literature as service barriers to accessing prenatal care. This was
corroborated in the results through the qualitative finding that many women experience long wait
times at their appointments. This is even more significant since public sites, who were the only
sites to report accepting uninsured and uninsurable patients, only provided hours before 8:00am
one day a week at one site.
A number of the qualitative results for barriers to providing prenatal care at their sites
were consistent with the literature. These similarities included access to transportation, length of
wait time at an appointment, difficulty in initiating first appointment, perception of prenatal care
as important, and having an unintended pregnancy. While this study does not address quality of
care, these findings suggest the need for future study and policy to address these bariers to
receiving prenatal care in Philadelphia.
The use of the Community Coalition Action Theory (CCAT) provides an opportunity for
a unique collaboration among the 64 sites providing prenatal care and community leaders and
maternal health organizations. The qualitative results revealed that the six major OB unit chairs
were already meeting to address issues related to quality of care. Expanding the representation of
leadership to include representatives from the public health centers and members of the
community would strengthen community engagement and partnership. The “Synergy” stage of
the theory provides for the pooling of resources, member engagement, and assessment and
planning. Since a leadership panel already exists to assess issues of quality of care that may
36
contribute to poor birth outcomes, it may be helpful to have a larger community representation to
be able to expand resources and member engagement.
Furthermore, the theory allows for implementation of strategies. With a large
membership base and representation of the community, implementing strategies will allow the
policies to reach multiple levels of the system that go beyond the six major OB units, increasing
impact and potentially intensifying the overall goal of improving the poor birth outcomes in
Philadelphia. Additionally, including the community in the leadership and implementing change
at the community level builds community capacity among community members. This provides
the opportunity to determine the level of overlap between the needs from the perspective of the
researchers represented in literature and the perspective of the community leadership
incorporated through the CCAT.
Limitations
When trying to reach prenatal care sites directly by phone, various barriers were
experienced. Sites were often very busy processing patient phone calls and meeting the demand
of the high patient volume. Additionally, site personnel found it difficult to determine who would
be the appropriate person to complete the survey. It was also difficult to navigate answering
systems at sites to be able to reach someone internally. Often the researcher was not permitted to
obtain contact name or phone number for the person for which the message was being left. This
also created further difficulty to follow up with participants directly to remind them to participate
in the study after receiving the survey monkey link, contributing to the overall low response rate.
Multiple sites asked if there would be an incentive for participating in the study. An
incentive for this study was not provided, which potentially further contributed to a low response
rate. The research team also experienced difficulty in identifying a private provider to participate
37
in a qualitative interview. Three of the four qualitative respondents confirmed that only three
private practitioners remain in the city of Philadelphia. This greatly reduced the potential
population of private pracitioners to participate in a qualitative interview.
After investigating IRB approval with the city, the researchers were assured by PDPH
collarborators that it would not be necessary to seek city IRB approval if Drexel IRB approved
the protocol which was completed successfully. However, in the late spring, reserachers were
notified that any further city health center data could not be obtained and previously collected
data could not be used in the study until an application for city IRB approval was submitted and
approved. This greatly impacted participant response and the representation of data for public
facilities.
Since the sample size was rather small, N=20 of a possible 64 participants, many of the
findings have additional limitations. To improve the power of the statistical significance testing,
the participant size would need to be larger and more data would need to be available. A larger
sample size would also increase the significance of the quantitative findings of this study and
allow for external validity in order for meaningful conclusions to be transferrable. In addtion to
the sample size limitation, the mixed methods design includes the limitation of causation. While
correlation does not directly infer causation, the association does provide a potential explanation
for the cause.
Conclusions
Quantiative results suggest that there is an inadequate number of sites that provide
prenatal care hours outside of the 8am-5pm Monday-Friday time interval. Provider workforce is
also inadequate with 85% of sites having 5 or fewer providers and a FTE workforce of only 19.8
providers or 22% of the total possible 100% workforce. Additionally, an inadequate number of
38
appointments are available for new patients with only 15% of all appointments available to
them.
Wait time for initial prenatal care appointment is inadequate with a wait time of 10.26
days across all sites. Statistically significant differences were found between the percentage of
public facilities that accept uninsured and uninsurable patients compared to the private facilities,
providing a picture for where these patient populations receive their care. Many of the qualitative
results were consistent with the literature and support quantitative data conclusions.
Recommendations
Prenatal care hours need to be extended beyond the 8am-5pm Monday-Friday interval to
accommodate working mothers and those who receive other support services. Philadelphia’s
prenatal care provider workforce needs to be increased to meet the demand of more than 23,000
births annually across only 64 prenatal care sites. In order to accommodate this increaseit is
important for hospitals and health centers to consider the potential for other types of providers to
be utilized for prenatal care. Obstetric care systems should implement programs that partner with
professional programs to incentivize these types of providers to practice as prenatal care
providers through loan reimbursement. Obstetric cares systems should also consider the use of
birth doulas as patient navigators and coordinators of care.
Institutional policies for scheduling need to be streamlined and standardized across
prenatal care providers in order to help address the long wait times across the different patient
groups (e.g. first trimester patients, second trimester patients, medically high risk patients, etc).
Addtionally, the intersectinoality of multiple socioeconomic, systemic, and political barriers to
providing prenatal care need to be addressed. The MCFH Division of the PDPH should distribute
informational brochures with accurate listings of locations to obtain prenatal care and institute
39
public awareness camapigns of the importance of prenatal care through preconception care
before women get pregnant. Furthermore, implementation of an annual city-wide surveillance of
prenatal care capacity is necessary and should be under the guidance of the PDPH. Partnerships
grounded in the Community Coalition Action Theory (CCAT) between the academic medical
centers, the city health centers, and the public health department are critical and necessary to
institutionalize change and improve health outcomes.
40
Bibilography ACOG Committee on Genetics. (2004). ACOG committee opinion. number 298, august 2004. prenatal and preconceptional carrier screening for genetic diseases in individuals of eastern european jewish descent. Obstetrics & Gynecology, 104(2), 425-428. Alexander, G. R., & Kotelchuck, M. (2001). Assessing the role and effectiveness of prenatal care: History, challenges, and directions for future research. Public Health Reports (1974-), 116(4), 306-316. doi:10.1093/phr/116.4.306 Alexander, G. R., Kogan, M. D., & Nabukera, S. (2002). Racial differences in prenatal care use in the united states: Are disparities decreasing? American Journal of Public Health, 92(12), 1970-1975. doi:10.2105/AJPH.92.12.1970 Arias, E., MacDorman, M. F., Strobino, D. M., & Guyer, B. (2003). Annual summary of vital statistics--2002. Pediatrics, 112(6 Pt 1), 1215-1230. doi:10.1542/peds.112.6.1215 Beckmann, C. A., Buford, T. A., & Witt, J. B. (2000). Perceived barriers to prenatal care services. MCN.the American Journal of Maternal Child Nursing, 25(1), 43-46. doi:10.1097/00005721-200001000-00009 Bennett, I., Switzer, J., Aguirre, A., Evans, K., & Barg, F. (2006). 'Breaking it down': Patient-clinician communication and prenatal care among african american women of low and higher literacy. Annals of Family Medicine, 4(4), 334-340. doi:10.1370/afm.548 BergsjØ, P., & Villar, J. (1997). Scientific basis for the content of routine antenatal care. Acta Obstetricia Et Gynecologica Scandinavica, 76(1), 15-25. doi:10.3109/00016349709047779 Bishop, G. (2006). Childbirth at a crossroads in southeastern pennsylvania. Philadelphia: Maternity Care Coalition. Boudreau R.M., McNally C., Rensing E.M., Campbell, M.K. (2004). Improving the timeliness of written patient notification of mammographyresults by mammography centers. The Breast Journal. Jan-Feb;10(1):10-19. CDC 2008. National Vital Statistics Reports, Volume 56, Number 16. Deaths: Preliminary Data for 2006. Cogan, L. W., Josberger, R. E., Gesten, F. C., & Roohan, P. J. (2012). Can prenatal care impact future well-child visits? the experience of a low income population in new york state medicaid managed care. Maternal and Child Health Journal, 16(1), 92-99. doi:10.1007/s10995-010-0710-8 Cordivano, S. (2010). Measuring the impact of a decade of labor and delivery unit closures in philadelphia. (Unpublished Masters of Urban Spatial Analytics). University of Pennsylvania, Pennsylvania.
41
Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). Chapter 1 overview of obstetrics. In Williams obstetrics (23rd ed., ). United States of America: The McGraw-Hill Companies, Inc. Retrieved from http://www.accessmedicine.com.ezproxy2.library.drexel.edu/content.aspx?aID=6020001 Curhan, G. C., Willett,W. C., Rimm, E. B., Spiegelman, D., Ascherio, A. L., & Stampfer, M. J. (1996). Birth weight and adult hypertension, diabetes mellitus, and obesity in U.S. men. Circulation, 94(12), 3246–3250. Dooley, E. K., & Ringler, J.,Robert L. (2012). Prenatal care: Touching the future. Primary Care, 39(1), 17-37. doi:10.1016/j.pop.2011.11.002 Donabedian A. (1980). The definition of quality and approaches to its assessment. Chicago: Health Administration Press. Finnegan LP, Sheffield J, Sanghvi H, Anker M. (2004). Infectious diseases and maternal morbidity and mortality. Emerg Infect Dis; Nov 2004. Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco: Jossey-Bass. Hack, M., Klein, N. K., & Taylor, H. G. (1995). Longterm developmental outcomes of low birth weight infants. Future Child, 5(1), 176–196. Hamilton, B., Martin, J., & Ventura, S. (2011). Births: Preliminary data for 2010. National Vital Statistics Reports, 60(2), 1-36. Headley, A. J., & Harrigan, J. (2009). Using the pregnancy perception of risk questionnaire to assess health care literacy gaps in maternal perception of prenatal risk. Journal of the National Medical Association, 101(10), 1041. Jessop, A. B., Watson, B., Mazar, R., & Andrel, J. (2005). Assessment of screening, treatment, and prevention of perinatal infections in the philadelphia birth cohort. American Journal of Medical Quality : The Official Journal of the American College of Medical Quality, 20(5), 253-261. doi:10.1177/1062860605279474 Johnson, A. A., El-Khorazaty, M. N., Hatcher, B. J., Wingrove, B. K., Milligan, R., Harris, C., & Richards, L. (2003). Determinants of late prenatal care initiation by african american women in washington, DC. Maternal and Child Health Journal, 7(2), 103-114. doi:10.1023/A:1023816927045 Kirkham, C., Harris, S., & Grzybowski, S. (2005). Evidence-based prenatal care: Part I. general prenatal care and counseling issues. American Family Physician, 71(7), 1307-1316.
Kogan, M. D., Martin, J. A., Alexander, G. R., Kotelchuck, M., Ventura, S. J., & Frigoletto, F. D. (1998). The changing pattern of prenatal care utilization in the united states, 1981-1995, using
42
different prenatal care indices. JAMA: The Journal of the American Medical Association, 279(20), 1623-1628. doi:10.1001/jama.279.20.1623
Kotelchuck, M. (1994). An evaluation of the kessner adequacy of prenatal care index and a proposed adequacy of prenatal care utilization index. American Journal of Public Health, 84(9), 1414-1420. Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7, 13–30. Lu, M. C., & Chen, B. (2004). Racial and ethnic disparities in preterm birth: The role of stressful life events. American Journal of Obstetrics and Gynecology, 191(3), 691-699. doi:10.1016/j.ajog.2004.04.018 Markovitz, B. P., Cook, R., Flick, L. H., & Leet, T. L. (2005). Socioeconomic factors and adolescent pregnancy outcomes: Distinctions between neonatal and post-neonatal deaths? BMC Public Health, 5(1), 79-79. doi:10.1186/1471-2458-5-79 National Center for Health Statistics, Centers for Disease Control and Prevention. (2010). Births and natality. FastStats. Hyattsville, MD: Available from http://www.cdc.gov/nchs/fastats/births.htm National healthcare quality report (NHQR) (2011). Sage Publications. Nicolaides, K. (2011). A model for a new pyramid of prenatal care based on the 11 to 13 weeks’ assessment. Prenatal Diagnoisis, 31, 3-6. Pennsylvania Department of Health. (2010). Health Statistics and Research, Resident Live Births by Age of Mother, Counties and Pennsylvania. Pennsylvania Department of Health. (2009). Maternal and Child Health Status Indicators, Philadelphia City. Pennsylvania Department of Health. (2010). Resident Infant Deaths by Age, Sex, Race and County, Pennsylvania 2010. Prenatal care (2004). Harvard University Press. Roberts, R. O., Yawn, B. P., Wickes, S. L., Field, C. S., Garretson, M., & Jacobsen, S. J. (1998). Barriers to prenatal care: Factors associated with late initiation of care in a middle-class midwestern community. The Journal of Family Practice, 47(1), 53. Rouse, H. L., Fantuzzo, J. W., & LeBoeuf, W. (2011). Comprehensive challenges for the well being of young children: A population-based study of publicly monitored risks in a large urban center. Child & Youth Care Forum, 40(4), 281-302. doi:10.1007/s10566-010-9138-y
43
Shi, L., Stevens, G. D., Wulu, J.,John T., Politzer, R. M., & Xu, J. (2004). America's health centers: Reducing racial and ethnic disparities in perinatal care and birth outcomes. Health Services Research, 39(6 Pt 1), 1881-1902. doi:10.1111/j.1475-6773.2004.00323.x
Simic, M., AmerWåhlin, I., Marsal, K., Källén, K., Division V, Reproductive Epidemiology/Tornblad Institute, . . . Reproduktiv epidemiologi/Tornbladinstitutet. (2011). Differences in ultrasonically estimated gestational age of extremely preterm infants when using various dating formulas. Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
Shojania K., McDonald K., Wachter R., (2007). Closing the quality gap: a critical analysis of quality improvement strategies—Volume 7: Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality; Available at :http://www.ahrq.gov/clinic/tp/caregaptp.htm.
Stoll, B. J., Gordon, T., Korones, S. B., Shankaran, S., Tyson, J. E., Bauer, C. R., et al. (1996). Late onset sepsis in very low birth weight neonates: A report from the National Institute of Child Health and Human Development Neonatal Research Network. Journal of Pediatrics, 129(1), 63–71.
Thompson, L. A., Goodman, D. C., & Little, G. A. (2002). Is more neonatal intensive care always better? insights from a cross-national comparison of reproductive care. Pediatrics, 109, 1036-1043. Tossounian, S. A., Schoendorf, K. C., & Kiely, J. L. (1997). Racial differences in perceived barriers to prenatal care. Maternal and Child Health Journal, 1(4), 229-236. doi:10.1023/A:1022370627706 VanderWeele, T. J., Lantos, J. D., Siddique, J., & Lauderdale, D. S. (2009). A comparison of four prenatal care indices in birth outcome models: Comparable results for predicting small-for-gestational-age outcome but different results for preterm birth or infant mortality. Journal of Clinical Epidemiology, 62(4), 438-445. Vintzileos, A. M., Ananth, C. V., Smulian, J. C., Scorza, W. E., & Knuppel, R. A. (2002). The impact of prenatal care in the united states on preterm births in the presence and absence of antenatal high-risk conditions. American Journal of Obstetrics and Gynecology, 187(5), 1254-1257. doi:10.1067/mob.2002.127140 van Wassenaer, A. (2005). Neurodevelopmental consequences of being born SGA. Pediatric Endocrinology Reviews, 2(3), 372–377. Wiles, N. J., Peters, T. J., Leon, D. A., & Lewis, G. (2005). Birth weight and psychological distress at age 45–51 years: Results from the Aberdeen children of the 1950s cohort study. The British Journal of Psychiatry, 187, 21–28.
APPENDIX A
Quantitative Survey
APPENDIX B
Qualitative Interview Questions
1) How has prenatal care capacity changed at your site in the last 5-10 years? A. Has it increased or decreased?
2) Describe barriers that prohibit providing prenatal care at your site. 3) What facilitates your ability to provide prenatal care at your site? 4) What are three action steps you feel should be taken to ensure all women in Philadelphia
receive prenatal care?
APPENDIX C
Informational Letter to Sites
Maternal & Child Health Working Group Drexel University School of Public Health
The Maternal and Child Health Working Group (MCHWG) at the Drexel University School of Public Health is building on a pilot study conducted in 2010/2011 to carry out a prenatal care capacity assessment within the City of Philadelphia. The MCHWG is a multidisciplinary group of academics, clinicians and policy makers who strive to improve the health of women and children through education and research. This assessment is being conducted in collaboration with the Division of Maternal, Child and Family Health at the Philadelphia Department of Public Health and the Maternity Care Coalition. The primary goal of this study is to determine the extent of prenatal care capacity, both public and private, available to pregnant women in Philadelphia. As you may know, 13 hospitals have closed their inpatient obstetrical units (OB) since 1997. An additional six OB unit closures in the counties surrounding Philadelphia may be increasing the number of patients at the remaining Philadelphia hospitals. There is concern that prenatal care capacity has been dramatically affected by these closures and may in part be responsible for the inadequate maternal and child health practices in the city. Results of this assessment have the potential to positively impact maternal and child health practices in the city related to reducing infant mortality and poor birth outcomes. Furthermore, results of this assessment will be most important in developing future and more comprehensive research on these issues as well as informing policy at the local, state and federal levels. Currently, the city's capacity to provide access to early and adequate prenatal care is unknown. Therefore, we are asking for your help so we can begin to address the gaps and needs in prenatal care services in our city. The individual completing the survey should have knowledge of your site's prenatal care services as well as the insurance plans accepted by the site and practitioners. Survey responses should be specific to one site. Therefore, an individual selected as the "point person" to complete the survey for multiple sites should submit one survey per site. Participation in this study is voluntary and no link will be published between the subject completing the survey and the answers submitted. Thank you in advance for your time and we look forward to speaking with you in the near future. Sincerely, Dr. Nathalie Bartle, Ed.D. Maternal & Child Health Working Group, Drexel University School of Public Health Deborah Roebuck Division of Maternal, Child and Family Health, Philadelphia Department of Public Health
APPENDIX D
Community Coalition Action Theory (CCAT)
APPENDIX E
Identified Prenatal Care Sites in Philadelphia
Site Name Address 1 Address 2 City State Zip Code
1 Women’s Healthcare Group 7996 OXFORD AVE Philadelphia PA 19111
2 Health Center #2 1720 S BROAD ST Philadelphia PA 19145 3 Health Center #3 555 S. 43rd St Philadelphia PA 19104 4 Health Care Center #4 4400 Haverford Ave Philadelphia PA 19104 5 Health Center #5 1900 N. 20th St Philadelphia PA 19121 6 Health Care Center #6 321 W. Girard Ave Philadelphia PA 19123 7 Health Center #9 131 E. Chelten Ave Philadelphia PA 19144 8 Health Center #10 2230 Cottman Avenue Philadelphia PA 19149
9 Strawberry Mansion Health Center
2840 West Dauphin Street Philadelphia PA 19132
10 Drexel OB/GYN Associates 216 N Broad St
Feinstein Bldg 4th Fl Philadelphia PA 19102
11 Drexel OB/GYN Associates 10 Shurs Ln Ste 205 Philadelphia PA 19127
12 Drexel OB/GYN Associates 10 Shurs Lane Suite 204 Philadelphia PA 19127
13
Women's Care Center, Drexel OB/GYN Associates 1427 Vine Street 7th Floor Philadelphia PA 19102
14 Drexel OB/GYN Associates 255 S 17th St
9th Floor, Medical Arts Bldg Philadelphia PA 19103
15 Einstein OB/GYN Associates 101 East Olney Ave Ste C5 Philadelphia PA 19120
16 Einstein OB/GYN Associates 7201 Rising Sun Ave Philadelphia PA 19111
17 Einstein OB/GYN Associates
7131-39 Frankford Avenue 2nd Floor Philadelphia PA 19141
18
Einstein Ob/Gyn Associates - Wadsworth Plaza
1602-04 Wadsworth Avenue Philadelphia PA 19150
19 Germantown Women's Health Associates 2 Penn Blvd Ste 108 Philadelphia PA 19144
20 Paley Einstein OB/Gyn Associates 5501 Old York Road Paley 3 Philadelphia PA 19141
21 Einstein OB/GYN 5401 Old York Road Klein 410 Philadelphia PA 19141 22 Abbottsford Falls 4700 Wissahickon Ave Philadelphia PA 19144
23 The Health Annex 6120-B Woodland Avenue 2nd Floor Philadelphia PA 19142
24
RHD 11Th St Family Health Service Drexel Prenatal Clinic 850 N 11TH ST Philadelphia PA 19123
25 GPHA Hunting Park 1999 W Hunting Park Ave Philadelphia PA 19140
26 GPHA Chinatown 930 Washington Ave Philadelphia PA 19147 27 GPHA Woodland Ave 5000 Woodland Ave Philadelphia PA 19143
28 GPHA Wilson Park Medical Center 2520 Snyder Ave Philadelphia PA 19145
29 GPHA Frankford Avenue Health Center 4510 Frankford Ave Philadelphia PA 19124
30 GPHA Southeast Health Center 800 Washington Ave Philadelphia PA 19147
31 Kramer OB/Gyn Associates 7901 Bustleton Ave Ste 100 Philadelphia PA 19152
32 HR Millennium OB/Gyn 9807 Bustleton Ave Philadelphia PA 19115
33 Helen O. Dickens Center for Women's Health 3400 Spruce St 1 West Gates Philadelphia PA 19104
34 Division of Maternal Fetal Medicine 3400 Spruce St
2000 Courtyard Bldg Philadelphia PA 19104
35 Penn Family Care OB 3819 Chestnut St Ste 205 Philadelphia PA 19104
36 Penn OB/GYN Associates 3701 Market St 3rd Flr Philadelphia PA 19104
37 Covenant House Health Services-OB/GYN
251 East Bringhurst Street Philadelphia PA 19144
38 Delaware Valley Community Health
401-55 W Allegheny Ave Philadelphia PA 19133
39 Parkview OB/Gyn 841 E Hunting Park Avenue Philadelphia PA 19124
40 Fairmount Primary Care Center
1412 FAIRMOUNT AVE PHILADELPHIA PA 19130
41 Advanced Women’s Care PC 10752 Bustleton Ave Philadelphia PA 19116
42 Patricia McCauley Sunday, CNM 7602 Central Ave
Stapeley Bldg Ste 103 Philadelphia PA 19111
43 Dr. Girard Reme 5217 N BROAD ST IST FL Philadelphia PA 19140
44 Dr. Yvonne Prioleau 301 S 8TH ST STE 2A Philadelphia PA 19106
45 Jefferson OB/GYN Associates 834 Chestnut St Suite 300 Philadelphia PA 19107
46 Jefferson OB/GYN Associates 834 Chestnut St Ste 420 Philadelphia PA 19107
47 Jefferson Family Medicine/OB Care 833 Chestnut St Ste 301 Philadelphia PA 19107
48 Women and Children’s Health Sevices 700 Spruce St Ste 200 Philadelphia PA 19106
49 Penncare for Women 601 Walnut St Ste 220 Philadelphia PA 19106 50 Penncare OB/GYN 301 S 8TH ST STE 3D Philadelphia PA 19106
51 Broad Steet Health Center 1415 N Broad St 2nd Flr Philadelphia PA 19122
52 Haddington Health Center 5619-25 VINE ST Philadelphia PA 19139
53 Temple OB/GYN Assoiates 3401 N. Broad St
7th Floor, Outpatient Building Philadelphia PA 19140
54 Temple OB/GYN Assoiates 3425 N. Carlisle St Philadelphia PA 19140
55 Temple OB/Gyn Associates Roxborough 525 Jamestown Street Suite 201 Philadelphia PA 19128
56
Temple Physicians Inc, Women's Care at Northeastern
2301 East Allegheny Avenue 4th Floor Philadelphia PA 19134
57 Women's Center at Palmer Park 1741 Frankford Ave Ste 100-B Philadelphia PA 19125
58 TPI OB/GYN Lehigh 100 East Lehigh Avenue CHC-2 Philadelphia PA 19125
59 TPI Northeast 9331 Old Bustleton Ave Ste 203 Philadelphia PA 19115
60 Dr. Santiago 100 E LEHIGH AVE CHC2- E Philadelphia PA 19125
61 Michael A. Feinstein, MD, PC
829 SPRUCE ST STE 200 Philadelphia PA 19107
62 Philly Pregnancy Center, PC 201 A N 9TH ST Philadelphia PA 19107
63 Esperanza Health Center 3156 Kensington Ave Philadelphia PA 19134 64 Sayre Health Center 5800 Walnut Street Philadelphia PA 19139
APPENDIX F
Available Prenatal Care Hours at Private and Public Participant Sites
Public Site 1 Tuesday: 1pm-4pm; Friday: 9am-12pm
Private Site 1 Monday-Friday: 8am-5pm
Public Site 2 Thursday: 9am - 5pm
Private Site 2 Monday & Wednesday-Friday: 9am-5pm
Public Site 3 Monday-Friday: 8am-4pm
Private Site 3 Monday & Wednesday: 7:30am-5pm Tuesday: 8am-6pm; Thursday: 8am-5pm Friday: 8am-2:30pm
Public Site 4 Wednesday: 7:30am-5pm; Thursday: 1pm-5pm
Private Site 4 Monday-Friday 9am-4pm
Public Site 5 Thursday: 8am-12pm
Private Site 5 Monday & Wednesday-Thursday: 8:30am-5pm Tuesday: 8:30am-6:30pm
Public Site 6 Monday & Thursday: 1pm-5pm Wednesday: 9am-12pm
Private Site 6 Monday: 8:45am-6pm Wednesday: 8:45am-6:30pm Tuesday & Thursday-Friday: 8:45am-5pm
Public Site 7 Wednesday: 12pm-5pm
Private Site 7 Monday-Tuesday & Friday: 9am-4pm Wednesday: 9am-11:30am
Public Site 8 Monday-Friday: 8:30am-5pm
Private Site 8 Tuesday: 10am-6pm Wednesday-Friday: 9am-5pm
Public Site 9 Wednesday: 8:45am-5pm
Private Site 9 Tuesday-Friday: 8am-5pm
Private Site 10 Monday: 12pm-4pm; Tuesday: 12pm-7pm Wednesday-Thursday: 10am-4pm
Private Site 11 Monday & Wednesday-Friday: 9am-5pm Tuesday: 9am-6:45pm
