MCHB/EPI Miami Conference — December 7 - 9, 2005

Linking Data and Policy to Programs — Transcript

NAN STREETER: Good afternoon. Good afternoon? Is everybody awake? I just want to make sure since we just had lunch. It's a pleasure to be here today and as Russell said I'm going to be talking about improving adequacy of prenatal care in Utah .

I'd like to acknowledge the other folks from the department who are involved in working on this project and putting the data together. Laurie Baksh, Lois Bloebaum and Joanne Barley.

So just to give you a little background information, this background is probably known by everyone. Adequacy of prenatal care is actually of measure of access to prenatal care. It is a measure that is based upon the month of entry into care and the number of visits a woman has based on the duration of her pregnancy.

Just a reminder that inadequate prenatal care is a risk factor associated with low birth weight and other adverse pregnancy outcomes and that is why we are concerned about this particular issue.

Prenatal care does provide an opportunity for providers to assess a mother's risk for poor pregnancy outcomes. Both for herself as well as for her infant. To develop interventions that can reduce the risk and obviously provide some education about healthy behaviors, habits, practices during pregnancy. And obviously for women who are medically and socioeconomically high-risk, the risk reduction piece, the assessment piece, of prenatal care is particularly important. Since 1993 through 2000, Utah 's prenatal care adequacy has steadily declined. The United Health Foundations America's Health State Ranking's Report has put Utah at 39th in nation for adequacy beginning in the year 2000.

Just a word of note that they are releasing their newest report on Monday and while I'm not permitted to provide any specifics, the report does note some significant improvement in Utah 's adequacy of prenatal care since the last report. So we are thrilled to see this.

So here is a graph showing Utah 's prenatal care adequacy from 1994 to 2002 and you'll note that it did steadily decline up to the year 2000 and has started to increase slightly since then. We use PRAMS data for this particular intervention and looked at 1999 data and analyzed the prenatal care adequacy and various factors related to that and published a report in 2001. Using the Kotelchuck Index we found that the largest contributors to poor adequacy of prenatal care was actually women who missed appointments not women who did not get into care early.

And this circle or pie here shows you what the distribution is of adequacy of prenatal care for women in 1999 and as you can see, the largest piece of the pie related to inadequate prenatal care is related to insufficient visits. But we have 12.5 percent of women who are in the category of inadequate prenatal care because they did not get in early. So the analysis also showed that 61 percent of women that had inadequate prenatal care due to late entry reported that they received the prenatal care as early as they wanted to receive it. Indicating that perhaps Utah women may not be aware that first trimester prenatal care is important.

From the PRAMS data, from the findings of the analysis of the PRAMS data, the Reproductive Health Program in the Utah Department of Health embarked on a contract with a private company to do focus groups to look at why women were not getting adequate prenatal care. So six focus groups were held with women who had either late prenatal care or inadequate prenatal care who were identified and selected from birth certificate records. Interestingly, just as the data from PRAMS show us, the focus group participants did not appear to value prenatal care. A couple of quotes from the focus group included a statement that, "All women should have the same amount of care available to them but whether they take advantage of it or not, that is their choice." That clearly is saying that doesn't necessary reflect on any valuing. Then the second quote was, "I don't think it is necessary to go to the doctor if you don't want to. You can't change anything that is going to happen to the baby." This particular comment is not only concerning because the woman is saying that she doesn't think it is necessary for her to go to the doctor if she doesn't want to but also the misperception about the potential impact of prenatal care on the outcome for the baby, and I would say also for the mom.

So using the data from the focus group and from the PRAMS, we developed a media campaign to target women who weren't getting in early and who didn't have sufficient number of visits. The campaign was built on the current program that we've had in Utah since 1987 that is called Baby Your Baby. It is a program that has name recognition throughout the state and actually there are other states that are using the same program.

So using the data, the education campaign was developed and the theme of it was 13 by 13 to target women getting into early prenatal care and women who don't receive enough visits. So commercial spots were developed that highlighted the message, see your provider by week 13 and see your provider 13 times for a healthy pregnancy. And also another theme was 13 is your lucky number. We really wanted to highlight and attract the attention around the number 13 because most people associate it with bad luck and so we were communicating that this is good luck.

So I'm going to show you a couple of spots that were developed so you can see for yourself. Hopefully this will work. I'm going to call up my technical consult. Why is the picture not coming up? Well, we'll see what the next one looks like. We did check this out before and it worked just fine so I apologize.

(Video Clips Playing)

NAN STREETER: This next one was actually an award winning spot. It was a regional award.

VIDEO CLIP: Baby Your Baby wants to help you have a happy healthy baby. Call us or visit ww.BabyYourBaby.org.

NAN STREETER: So, sorry about the technical difficulties but it gives you a flavor of the media spots and how they would attract somebody's attention watching them. We began airing the spots in March of 2003 on Utah 's CBS station and also Spanish ads were developed and presented on several local Spanish stations. We had radio spots and billboards and newspaper ads throughout the state.

We wanted to evaluate the effectiveness of the campaign and so we developed a survey to determine the effectiveness in changing women's behavior and that survey began about 15 months after the initiation of the medial campaign. The participants were chosen from a sample of women who had delivered a live infant in the previous two to four months. We did over sample for women with lower educational levels using that as a marker for women living in poverty.

The one page questionnaire was mailed out to women to ask them about their feelings about the ads and also to determine whether or not the ads actually changed their perceptions about prenatal care or motivated them to seek early and continuous care. Two mailings were sent out and included with that, as an incentive was a 20-minute pre-paid phone card. The overall response rate though lower than we had hoped was 41 percent. Surveys were sent to more than 1,500 women and 600 responded.

So in terms of the findings, 94 percent of the women indicated that before their pregnancy they really did think women should start prenatal care in the first trimester which is interesting because that's not what the actual data show us in terms of behaviors. In terms of the number of visits, there was a wide variety of responses but you'll note that the majority of responses, more than 70 percent, were women who said 9 to 16 visits were appropriate number of visits so they are sort of in the ball park. Seventy percent of women said they had seen the 13 by 13 commercial on TV, 34 percent said that they had heard a 13 by 13 commercial on the radio. Almost 40 percent of women said they had seen a billboard. Interesting, only 22.6 percent of women said they had not seen any of the media spots.

So the question is did we motivate women? Also 32 percent of women said that the commercials did motivate them to call their health care provider for an appointment. Of the women who indicated that the ads did not motivate them said that it was because they already knew that early prenatal care was important or they had already engaged with their provider. And 46 percent said the commercials did motivate them to get prenatal care.

So were there differences in prenatal care? Did the ads actually work in terms of changing the behaviors of women? In comparing the women who saw an add to women who did not see an ad, there were significant differences in the trimester of entry, the number of visits they received and the adequacy of prenatal care.

And as you can see, this is a more current graph of Utah's adequacy of prenatal care and you can see from 2000 to 2004, we are seeing an increase in adequacy of prenatal care, and in particular a large jump in 2003 that has continued in 2004.

So conclusions. A targeted media campaign can be an important way to raise awareness about the importance of adequate prenatal care. Utah 's adequacy rates are at an all high but obviously we still have more work to do to reach the Healthy people 2010 goals.

Thank you.