Conference Summary Report

Improving Maternal Health Care:The Next Generation 

of Research on Quality, Content, and Use of Services

September 18-19, 2000

Airlie Conference Center

Warrenton, VA

Prepared for:

Agency for Healthcare Research and Quality

Rockville, MD

AHRQ Publication No. 02-0025

June 2002
ii

Acknowledgments

We are grateful for the contributions of Carolina Reyes, M.D. At the time of this meeting, she was a

Senior Scholar-in-Residence with the Agency for Healthcare Research and Quality (AHRQ). Dr.

Reyes provided tremendous leadership in conceptualizing and convening this meeting. 

The meeting was the product of shared interests and resources from several components of the U.S.

Department of Health and Human Services—the first DHHS-wide meeting on maternal health care

in about 10 years. We thank Christine Schmidt, M.P.A., in the Office of the Assistant Secretary for

Planning and Evaluation (OASPE); Carolyn Clancy, M.D. and Lisa Simpson, M.B., B.Ch., of the

Agency for Healthcare Research and Quality; Doris Barnette, M.S.W., of the Health Resources and

Services Administration (HRSA); Sumner Yaffe, M.D., of the National Institute of Child Health and

Human Development, National Institutes of Health (NICHD/NIH); and Lynne Wilcox, M.D.,

M.P.H., of the Centers for Disease Control and Prevention (CDC) for their commitment to

development of a coordinated, interagency research agenda in maternal health.

The planning committee benefitted from the advice and assistance of many people. Agency

representatives included: 

Marcy L. Gross

Project Director and Senior Advisor on Women’s Health

Agency for Healthcare Research and Quality

Andrea Pernack, M.P.H.

Co-Project Director and Health Policy Analyst

Office of the Assistant Secretary for Planning and

Evaluation, DHHS

Caroline Taplin, M.P.H.

Senior Policy Analyst

Office of the Assistant Secretary for Planning and

Evaluation, DHHS

Peter Van Dyck, M.D., M.P.H.

Associate Administrator

Health Resources and Services Administration

We also thank Lawrence Bartlett, Ph.D., Director, Health Systems Research, Inc. (HSR), Washington,

DC, for his help in planning the meeting and facilitating the discussion; Kate Lynch Machado, also of

HSR, who managed meeting logistics; and Rania Awad, who provided meeting notes and draft

proceedings.

We are also immensely grateful to the distinguished speakers and panel members who contributed

their time and expertise. They are listed in Appendix B.
iii

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Conference Summary Report

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Prenatal Care: Current Context and Key Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Specific Issues and Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Scope, Content, and Outcomes of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Models for Delivering Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Data and Information Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Translating Research into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Getting Started: A Dialogue with Senior DHHS Officials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Content of Maternal Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Quality of Maternal Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Disparities in Access, Use, and Delivery of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Intervention Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Data and Information Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Translating Research into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Appendix A: Meeting Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix B: List of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Appendix C: Listing of Recent Prenatal Care Research Sponsored by DHHS . . . . . . . . . . . . . . 25
The information presented in this report does not necessarily represent the position or opinions of the

Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

iv
Background

A 1985 Institute of Medicine (IOM) report of

the Committee to Study the Prevention of Low

Birthweight promoted the enrollment of all

pregnant women into a system of prenatal care

as a national policy to reduce the risk of low

birthweight (Institute of Medicine, 1985). This

report was followed by Congressional initiatives

that expanded Medicaid eligibility to include

pregnant women. The policy actions sparked by

the IOM report were based on the premise that

increasing early initiation and adequate use of

prenatal care would reduce the risk of low

birthweight (LBW) and preterm birth, thus

resulting in lower infant mortality rates

(Alexander and Howell, 1997). Although

prenatal care continues to be widely touted as an

effective approach to reducing low birthweight

and preterm births, a decade of further research

has raised questions about the impact of prenatal

care on LBW rates. As a result, the Department

of Health and Human Services (DHHS) decided

to reexamine its maternal health care research

agenda.

In September 2000, DHHS convened a

conference to discuss the next generation of

research in maternal health care, with a focus on

issues related to the content, quality, and use of

maternal health care services. Five components

within the DHHS—the Agency for Healthcare

Research and Quality (AHRQ), the Office of the

Assistant Secretary for Planning and Evaluation

(OASPE), the Health Resources and Services

Administration (HRSA), the National Institute

for Child Health and Human Development

(NICHD), and the Centers for Disease Control

and Prevention (CDC)—cosponsored the

meeting. It brought together experts from

different parts of the system to identify research

gaps and priorities and to suggest how to turn

those research needs into questions. The overall

objectives for the meeting were to:

• Identify methods to evaluate the quality,

content, and use of maternal health care.

• Identify mechanisms to increase the speed by

which research findings are disseminated and

transferred into practice, programs, and

policies.

• Identify health services research efforts

necessary to build on and extend our

understanding of ways to prevent low

birthweight and preterm births.

• Assess the cost-benefit and cost-effectiveness

of factors that promote and predict improved

outcomes related to low birthweight and

preterm births.

• Identify research topics and strategies to assess

the impact of behavioral interventions during

pregnancy for different groups of women.

The report presents a summary of the

conference. A copy of the meeting agenda is

presented in Appendix A, and a list of

participants appears in Appendix B. A listing of

recent research projects sponsored by DHHS

agencies is presented in Appendix C.

Prenatal Care: Current

Context and Key Issues

In his opening presentation, “Are We Ready to

Assess the Content of Prenatal Care?” Milton

Kotelchuk, Ph.D., M.P.H., reviewed many of the

key issues that led to the need for this

conference. He noted the confusion over what is

meant by “prenatal care,” a concept that has

been enlarged from being a strictly medical

(obstetrical) visit to become a public health

intervention. This shift resulted in new issues

related to access, changing content, and new

theories of causation around poor birth

outcomes. 

Over the last decade, the definition of prenatal

care has been expanded to include other ancillary

3

Improving Maternal Health Care:The Next Generation of

Research on Quality, Content, and Use of Services
services occurring during the antenatal period

(e.g., nutrition, education, and psychosocial

services). Alternate sources of prenatal

intervention also have begun to receive attention

(e.g., the impact of outreach workers, family

members, and the community in providing

prenatal services and information). Today, the

expanded focus is on maternal health care, a

concept that encompasses preconception,

prenatal, and postnatal care. So from an initial

focus on preventing maternal mortality, the role

of prenatal care has progressed to encompass: 

1. The detection, treatment, and prevention of

adverse maternal, fetal, and infant outcomes.

2. The amelioration of adverse health behaviors

and socioeconomic conditions.

Dr. Kotelchuk also discussed the three major

factors leading to changes in health policy:

changes in our knowledge base, social strategies,

and/or political will. He emphasized that in the

late 1980s and early 1990s, there was a

consensus across the public health community

and the Federal Government that the knowledge

base was sufficient for developing a series of

public interventions related to prenatal care (e.g.,

Medicaid expansions, Healthy Start).

Unfortunately, the efficacy of many of the

original components of prenatal care was never

rigorously established, nor have there been

periodic reviews of the evidence for standards.

Most of the recent research has focused on the

relationship between prenatal care use and low

birthweight, ignoring the number of alternative

outcomes that may be affected by prenatal care.

Some of the questions raised by Dr. Kotelchuk

include: 

• What range of maternal and infant health

outcomes are we trying to influence?

• What are the causal models underlying each

of the negative outcomes? 

• How can we measure the effects of

interventions on outcomes? 

• What range of maternal and antenatal health

services that should be considered

interventions? 

• Are any interventions associated with poor

outcomes?

A subsequent presentation by Robert

Goldenberg, M.D., “Pre-Term Birth: Next Steps

After the Low Birthweight PORT Study,”

focused on one of many possible prenatal

outcomes: preterm birth. Although preterm

births account for just 10 percent of total births,

preterm birth is a factor in 75 percent of

perinatal mortality and 50 percent of neurologic

handicap. 

In 1992, the Agency for Healthcare Research

and Quality funded a Patient Outcomes

Research Team (PORT) study to examine low

birthweight in minority and other high-risk

women (Patient Outcomes Research Team,

1998). Dr. Goldenberg noted that the PORT’s

outcomes of interest were not only preterm

birth, but also included the relationship between

low birthweight and preterm births and

maternal/fetal mortality, long-term handicap,

and severe neonatal morbidity.

Focusing on all of these outcomes, the PORT

researchers reviewed the research on 11 common

interventions thought to have an impact on

reducing the incidence of preterm birth. These

interventions included: prenatal care, risk

screening, nutrition counseling, bed rest,

hydration, home uterine activity monitoring,

and caloric, protein, and/or iron

supplementation. The PORT researchers

concluded that there was no evidence to support

the usefulness of any of these interventions in

reducing rates of preterm birth. 

Although prenatal care was found to

substantially reduce the rate of stillbirths and

term neonatal mortality, it had no or only

marginal effects on preterm birth rates or

survival rates of low birthweight infants. The

lesson learned from this experience is that before

other interventions are adopted, there first

should be evidence on the effectiveness,

ineffectiveness, or harm of the intervention in

relation to a specific outcome. 

4
To achieve this, the field of maternal health care

would benefit from the development and

adoption of a rigorous approach to evaluating

new evidence, interventions, and/or technology.

Among the specific research questions identified

as critically important were the following:

• What strategies can be used for systematically

evaluating new interventions?

• What mechanisms exist for increasing use of

effective interventions and eliminating

ineffective or harmful ones?

• How do social and demographic factors affect

outcomes?

Specific Issues and Research

Needs

These and other presentations made during the

course of the meeting generated significant

discussion on a range of topics. These

discussions, including suggestions for specific

research topics and questions, are summarized

here.

Scope, Content, and Outcomes of Care

Participants agreed that while the relationship

between use of prenatal care and low birthweight

is almost always the exclusive focus of research,

there are a number of alternative perinatal

outcomes that may be modified by prenatal care

and are in need of further investigation. These

include maternal and fetal mortality, severe

neonatal morbidity, and long-term handicap.

Emphasis was placed on the importance of

identifying, very specifically, what prenatal care

should be designed to achieve. A starting point

could be to determine which specific prenatal

interventions affect which specific outcomes. To

fully understand the benefits of prenatal care on

specific outcomes, the modifiable adverse

outcomes that each component is intended to

ameliorate must be specified.

The controversy over the effectiveness of prenatal

care in preventing low birthweight also has

broadened to embrace the difficulties in defining

what constitutes adequate use of prenatal care.

There are many content areas (both medical and

social) that potentially can be incorporated into a

comprehensive prenatal care package, but it

simply is not feasible to include them all and

achieve improvements in all the associated

outcomes. 

One of the challenges faced by researchers is that

the purpose and content of prenatal care have

changed (and continue to change) over time.

Prenatal care has shifted from being a medical

(obstetric) intervention to a much broader public

health intervention where it now encompasses:

(1) the detection, treatment, or prevention of

maternal, fetal, and infant outcomes; and (2) the

amelioration of detrimental health behaviors and

socioeconomic conditions. 

Another fundamental problem facing researchers

is that the current standards of practice for

prenatal care were established without

randomized clinical trials to demonstrate the

efficacy of many of the components. Conference

participants seconded the opinion that there is a

pressing need for more systematic research into

the effectiveness of each of the many diverse

components of prenatal care, using outcomes

that can plausibly be modified through prenatal

care services. 

The discussion often returned to the idea of

prenatal care being viewed as a platform that

contains many specific components and

interventions. To evaluate each specific

intervention in an evidence-based manner, there

must be a way to single out individual

components of prenatal care that may be

beneficial for targeted outcomes.

There also was an overwhelming consensus

about the importance of moving beyond the

traditional concept of prenatal care to integrating

it into the broader concept of general women’s

health: what women need before they become

pregnant (preconception care), through the

pregnancy and delivery (prenatal care), and after

delivery (postpartum care). Current

interventions do not recognize that the prenatal

period is not the only period of risk for adverse

5
outcomes and therefore do not take advantage of

all opportunities for prevention. 

The following suggestions for future research

were offered:

• Define the objectives of maternal health care

services in relation to a range of specific

outcomes and expand research on the impact

of prenatal care to alternative outcomes

beyond preterm delivery and low birthweight

(e.g., maternal, perinatal, infant, and child

mortality and morbidity, health behaviors,

health care use).

• Identify which specific content of care

components within comprehensive prenatal

care packages may be beneficial for targeted

outcomes. Advance the use of randomized

controlled trials to assess their impact.

• Examine the recommendations of the IOM

Expert Panel on Content of Prenatal Care to

determine which prenatal care interventions

are supported with adequate evidence and

which unproven interventions require further

research.

• Redefine the concept of health care to

improve birth outcomes from an exclusive

focus on prenatal care to a continuum of care,

starting at preconception and running

through menopause. Fund more research on

the full spectrum of women’s experiences with

reproductive health services.

• Study the impact of reproductive health

management during the continuum of

maternal health care, with a focus not only

on the index pregnancy but also on

subsequent pregnancies to determine if

specific types of interventions have an impact

on overall reproductive health.

Models for Delivering

Interventions

In the presentation, “A Critical Reexamination of

Models of Intervention in Perinatal and

Maternal Health,” Vijaya Hogan, Dr.P.H.,

identified research strategies to better understand

the impact of behavioral interventions during

pregnancy for different groups of women and to

assess their long-term value in prevention.

Numerous previous studies have noted that

behavioral choices (e.g., smoking, diet, drug use)

account for a significant portion of preventable

fetal and maternal morbidity and mortality.

Therefore, behavioral and social interventions

offer great promise to reduce morbidity and

mortality, but their potential to improve public

health has not been fully tapped. An IOM report

(Smedley and Syme, 2001) noted that although

approximately 50 percent of mortality in the

United States is attributable to behavioral factors,

only 5 percent of all health care expenditures are

directed at improving the way social and

behavioral risks are addressed. When considered

in the context of the slow progress in achieving

desired outcomes, there is opportunity for

reassessing current models of intervention. 

According to the traditional model of addressing

current known risks, the risk factor first must be

identified, and then the effects of the risk factor

must be mediated. Dr. Hogan noted that,

unfortunately, many of the risk factors for

preterm delivery are not readily accessible for

intervention. Jack and Culpepper (1990) have

classified prenatal risk type into: 

1. Those factors mutable via changes in health

habits (e.g., diet, smoking).

2. Medical conditions not subject to change.

3. Medical conditions subject to change but for

which early detection and treatment can help

manage the risk.

4. Risks that cannot be changed by prenatal

intervention (e.g., age, race, previous

reproductive history). 

In treating the effects of risk, the symptoms

affecting the current pregnancy are eliminated,

but the social context stays the same. In

correcting the causes of risk, on the other hand,

there can be a greater effect on clinical

conditions because the context has been

changed, removing a fundamental cause.

Targeting intervention strategies at individual

6
women makes an incorrect assumption that their

behaviors exist outside of a social context. In

reality, there are several levels of influence on a

woman’s behavior, among them the family, social

network, social environment, and health care

providers. To be successful, any intervention

strategy would need to account for all members

of a woman’s extended family network that she

relies on for advice and material support. 

Dr. Hogan proposed a multilevel approach that

would first research and understand different

levels of influence on behavior and then design

and target a strategy to intervene on all those

levels. She also suggested that intervention

strategies should take full advantage of all

periods of risk as opportunities for prevention:

preconception, prenatal, during delivery, and

postpartum.

The following related suggestions for future

research were offered:

• Focus on the social determinants of maternal

health, including screening and interventions

regarding domestic violence and substance

abuse.

• Develop better interventions (and evaluations

of interventions) for complex problems (e.g.,

behavioral, social, biological, cultural) arising

in a diverse community.

• Examine what factors influence women’s

health knowledge and behaviors (e.g., Where

do they get their information?) and determine

the types of care different groups of women

prefer.

• Study the impact of social marketing

strategies (e.g., talk shows, soap operas) on

various behaviors.

• Improve the training of alternative types of

providers (e.g., nurses, midwives) to provide

care to women.

Special Populations

There is little definitive information on the

extent to which individual components of

standard prenatal care may be effective in

reducing or preventing adverse pregnancy

outcomes among different groups of women

with special medical conditions and

socioeconomic situations. However, there was

general agreement among conference

participants that the benefits of prenatal care

may not be equal for all population subgroups

and that there may be differences in use and

outcomes based on socioeconomic,

demographic, cultural, and medical risk factors. 

Indeed, participants were concerned about the

biomedical, behavioral, social, and cultural

factors that, singularly or in combination, are

often found in diverse communities but about

which little is known. Although they agreed that

a research agenda should address the “big

picture” (i.e., the entire nation), the agenda also

should include outlying population “pockets”

with major problems. These groups can be

defined by ethnicity, subethnicity, locale, or a

combination of factors. 

There was some agreement as to the importance

of carefully considering which subpopulations

are studied and how conclusions are derived

before translating one single study or

intervention on a large scale to different

populations where it may or may not have the

same effect.

The following suggestions for future research

were offered:

• Expand research to explore the varying

impact of prenatal care on diverse

populations as defined by medical,

demographic, cultural, and socioeconomic

characteristics and use multilevel statistical

modeling techniques to determine how each

of these factors independently affects

perinatal outcomes.

• Develop methods to find variations where

there are high rates of adverse outcomes,

determine why they occur, and evaluate

7
targeted interventions to reduce the high

rates.

• Investigate the consequences for maternal

health of women who were born and raised

in communities segregated on the basis of

socioeconomic status, race, and/or ethnicity.

• Examine whether there are racial and ethnic

disparities in the advice, content, or quality of

care provided by health care professionals. 

• Identify effective means to enhance cultural

sensitivity among providers.

• Identify factors that drive higher rates of

prematurity and other adverse outcomes in

black women.

• Identify and measure how structural

phenomena like social, economic, and power

inequalities (e.g., racism) directly influence

health outcomes.

• Examine the relationship between social

determinants and population-level

determinants in preterm delivery.

• Examine social, biological, economic, and

environmental contributors to racial and

ethnic disparities in maternal and infant

outcomes.

• Examine the barriers that may keep women

from entering systems of care.

Quality of Care

A background paper prepared for the meeting by

Carolina Reyes, at the time a visiting scholar at

the Agency for Healthcare Research and Quality,

highlighted the fact that although there has been

significant improvement in maternal and infant

health over the last century, the last decade has

shown a slow rate of improvement in maternal

and perinatal mortality and morbidity. When

considered in light of significant improvements

in medical technology, this reinforces the need to

place more emphasis on measuring and assessing

the quality and outcomes associated with

maternal health care. 

Furthermore, usually there are many providers

involved in a woman’s care, which greatly

increases the amount of data collected and

shared. This reinforces the need for improved

and more efficient mechanisms for information

flow. Also, traditional perinatal health indicators

are no longer sufficient to characterize the

underlying problems presented by many

pregnant women. Therefore, a quality

management strategy is needed to ensure that

the health care system will continue to evolve in

a comprehensive manner and remain responsive

to the individual needs of women.

A presentation by Kimberly Gregory, M.D.,

M.P.H., “Assessing Maternal Quality of Care,”

expanded the discussion on these points. She

emphasized that the historical paradigm of

adequacy of prenatal care being linked to

maternal and perinatal mortality and low

birthweight are no longer valid criteria as the

sole determinants of quality of maternal health

care. Poor quality, as defined by the Institute of

Medicine (Chassin and Galvin, 1998),

encompasses underuse (failure to provide a

beneficial health service), overuse (service

provided when potential for harm exceeds

benefit), and misuse (when the appropriate

service is given but a preventable complication

occurs). Dr. Gregory noted that although

prenatal care quality indicators currently exist

(e.g., Joint Commission on Accreditation of

Healthcare Organizations [JCAHO] and

American College of Obstetricians and

Gynecologists [ACOG] measures), there are no

measurements of their effectiveness or how often

they are being used. 

Several participants noted that there is little

consensus regarding quality measures in

obstetrics, due in part to a lack of consensus

regarding the objectives of care. The adequacy of

prenatal care is not easily measured because the

definition of adequacy continues to evolve. The

Kessner/IOM index (Kessner, Singer, Kalk, and

Schlesinger, 1973; Brown, 1988) and ACOG

standards (ACOG, 1974) both define adequacy

as the number of medical visits received.

Participants emphasized that this definition is

misleading because assuming that an increased

8
number of visits is indicative of quality care

misses an important confounder: that patients at

highest risk for adverse outcomes often are the

ones with the most visits. If future research is to

enhance understanding about the benefits of

prenatal care, the term “adequate care” must be

better defined.

Measuring quality in terms of whether a patient

receives the appropriate components of care also

presents a challenge because, as discussed

previously, there is no consensus on the

appropriate content of prenatal care. Many

content areas have changed considerably in the

past decade (e.g., smoking cessation, HIV/AIDS,

genetic testing, fetal monitoring). One

participant proposed measuring quality of care in

terms of whether services are delivered in an

appropriate manner and whether patient

satisfaction is achieved.

Addressing and improving quality of care also

includes identifying and eliminating ineffective

or harmful practices. Participants suggested that

the examination of old practice models that have

since been discredited could provide useful

information on developing strategies to eliminate

current harmful or ineffective interventions.

Some participants suggested doing a cost-benefit

analysis for practices that are suspected to be

ineffective.

Other issues that relate to quality focus on the

use of maternal health care services. Three

distinct issues affecting use of care were raised:

(1) defining and developing measures of prenatal

care use; (2) assessing whether prenatal care or

maternal health care services are actually being

used; and (3) assessing whether adequate use

affects birth outcomes (or other maternal health

outcomes).

Participants noted that adequacy of prenatal care

use indexes have been in use for nearly three

decades, but much improvement is needed. For

instance, current indexes of prenatal care use

have problems in controlling for gestational age

bias. The current measures also establish

adequacy by relying on ACOG

recommendations for low-risk mothers (ACOG,

1974). What is considered adequate care for

women with high-risk conditions has not been

fully explored. It remains unclear if the ACOG

standard is the best choice to define adequate

use.

The following suggestions for future research

were offered:

• Perform systematic evaluations of guidelines

or proposed indicators and define optimal

management and expected outcomes.

• Foster efforts to periodically evaluate

proposed prenatal care guidelines and

standards.

• Develop indicators across the continuum of

care and across all provider levels.

• Support networks and collaboration to allow

sharing of data and resources, permit

multimethod research designs, and

disseminate findings.

• Identify the most effective communication

and education practices for maternal health,

and study how physician-patient

communication affects satisfaction and other

outcomes in different types of settings.

• Develop potential quality indicators for

conditions or services specific to maternal

health care.

• Develop and validate new methods for the

measurement of quality in maternal health

care to include optimal outcomes, impact on

subsequent pregnancies, and unconventional

outcomes (e.g., decreased morbidity and

developmental handicaps).

• Examine how the coordination of obstetric

and primary care in different types of

organizations impacts on quality of care.

• Expand research on the adequacy of prenatal

care use, including improving the current

definition and measurement of adequate use,

exploring normal use patterns, and defining

adequate use for high-risk women.

• Explain patient variation (e.g., attitudes,

preferences, interpretation of informed

9
consent) and develop tools to integrate

patient satisfaction and expectations in

measuring quality.

• Explore the quality of maternal health care

services from women’s perspectives by

simultaneously collecting quality/service data

from both patients and their providers to

identify where disparities in perspectives exist.

• Create mechanisms and tools for providers

that promote adherence to and use of

standards.

Data and Information Needs

One overriding concern of participants was the

lack of a solid body of data that would provide

the foundation for conducting much-needed

research. More sophisticated methods for

collecting data about the prenatal experience are

needed to be able to associate particular

interventions with outcomes in a scientifically

sound manner. They argued that current data are

outdated, uncontrolled, biased, and

observational.

Some participants argued that some good data

are already available, but the data are not linked

together in some type of comprehensive system.

Each data system (e.g., Medicaid data,

administrative data) is insufficient in and of

itself, so there needs to be a way of bringing all

the systems together. They also noted that the

assessment of prenatal care quality rests on

having a comprehensive, nationwide electronic

medical record, but costs and other implications

have not been fully examined. Participants also

noted that since practitioners are already

required to keep records, Federal efforts could

examine how to link the records electronically to

allow for analysis using standardized data.

Participants also noted that in prenatal care,

social strategies (e.g., Medicaid expansions) have

far outpaced the knowledge base (e.g.,

knowledge about effectiveness of interventions).

The efficacy of many of the original aspects of

prenatal care was never rigorously established,

nor have there been periodic assessments of the

scientific evidence for prenatal care practice

standards as prenatal care evolved. Participants

agreed that a more systematic way is needed to

evalute interventions as they are developed.

Therefore, participants offered the following

suggestions for future research:

• Standardize key data elements, measures,

definitions, and fields and validate existing

data systems to determine which are useful

for research.

• Initiate a collaborative perinatal study to

gather and analyze obstetric and pediatric

information from selected hospitals across the

country.

• Develop a primary clinical information

database linked to secondary data (e.g.,

administrative data, managed care ambulatory

data) for a standardized clinical database for

the continuum of reproductive health to link

with outcomes, financial, and registry

databases. Examine the cost-effectiveness (and

other implications) of an electronic medical

record.

• Use Medicaid data to study the role of

Medicaid in family planning and abortion

services.

• Collect better data via vital records,

longitudinal studies on prenatal care, and

other services to women to better explain

population risk.

• Expand the medical component of the

national standard birth certificate, fetal death

certificate, and infant and maternal death

certificates, making them electronically

available. Teach institutions to use these data

to establish benchmarks.

• Develop and evaluate measurement tools and

monitoring systems for maternal health,

maternal outcomes, and health services

support.

• Develop and systematically validate practice

guidelines across all areas of women’s lives for

use by internists, family practitioners, and

obstetricians, including prenatal care

10
guidelines for high-risk and vulnerable

populations.

• Observe how data elements are linked to

outcomes by studying centers of practice that

use computerized systems incorporating

ACOG standards for measuring quality of

care.

• Initiate demonstration projects to collect

primary data based on a minimum data set

and integrate data into a clinical information

system.

• Develop national normative data of sentinal

events or rate-based indicators that have

already been described and stratified by age

and race/ethnicity and use these to develop a

consensus for standardized measures for casemix adjustment.

• Combine data into a repository of clinical

and administrative data and use the data to

develop a methodology to link structureprocess variables with outcomes of interest.

Translating Research Into Practice

Carolyn Clancy, M.D., Director of AHRQ’s

Center for Outcomes and Effectiveness Research

initiated a discussion about mechanisms and

strategies for building partnerships to facilitate

translation of research-based evidence. She

reviewed mechanisms through which existing

evidence could be evaluated and disseminated,

including: 

1. AHRQ-supported Evidence-based Practice

Centers (EPCs), which review and synthesize

existing evidence on specific clinical topics.

2. The Cochrane Collaboration, which has a

group that evaluates effective obstetrical

practices.

3. AHRQ’s Excellence Centers for Eliminating

Disparities, which is a grant program that

has the goal of strengthening the science base

for evaluating and implementing strategies to

eliminate differences in outcomes and health

status in minorities for six specific conditions. 

Dr. Clancy noted that there is an opportunity to

explore issues related to infant mortality. What

remains to be known is how researchers can

work with representatives of different

professional organizations first to prioritize a

research agenda and then throughout the

research project.

In response, participants suggested establishing a

better partnership between the practice

community and the practice evaluation

community, perhaps through an ongoing

consensus conference that would provide a better

link between the evaluation of practices and the

ultimate practices themselves. This type of

mechanism could facilitate the dissemination of

information about harmful or ineffective

interventions. This mechanism would be greatly

enhanced if the EPCS or other centers for

evidence synthesis could function as a virtual

knowledge base for findings, publications, and

decisions that are current.

One participant raised the point that although

prenatal care is constantly being examined by

various groups, it is a haphazard examination. If

too many groups are examining prenatal care

from too many perspectives and make many

different kinds of recommendations,

improvements in quality and/or outcomes will

not be achieved. Therefore, a forum could be

beneficial in bringing together the medical and

public health communities so an ongoing

dialogue can be established.

The following other suggestions for future

research were offered:

• Support research and education to create a

culture in which policymakers, providers,

payers, patients, and legislators recognize the

value of evidence-based practice.

• Develop a process for periodically revisiting

the evidence and a mechanism for

disseminating what is known about both

effective and ineffective interventions.

• Require that grants propose a plan for the

dissemination of research findings and

provide funding for dissemination activities.

11
• Identify appropriate methodologies for

dissemination research.

• Develop stronger interagency communication

and cooperation and work with the private

sector where cooperation would lead to better

initial designs for studies, analyses, and

applications.

• Promote the concept of a virtual knowledge

base in maternal health which posts (possibly

on the Internet) findings as they are

published, as well as standards, guidelines,

and results of consensus conferences.

• Coordinate and regularly update best

practices by linking and synthesizing

information from ACOG, AHRQ, the

Health Resources and Services

Administration (HRSA), and the Centers for

Medicare & Medicaid Services (CMS).

• Develop a mechanism for training the next

generation of clinical scientists to conduct

health services research.

Getting Started: A Dialogue

with Senior DHHS Officials

During the concluding session of the conference,

a representatives from each of the sponsoring

Federal agencies discussed their agency’s interest

and related activities in the area of maternal

health care and highlighted particular issues or

research questions that are important to their

own agency.

Doris Barnette, M.S.W., noted that HRSA,

sometimes called the “access agency,” links with

safety net providers and funds more than 700

community health centers and 2,100 National

Health Services Corps physicians. Between these

two groups, 11-12 million patients are served,

many of whom are pregnant women and even

more of whom are in the

preconception/interconceptional phase. Ms.

Barnette noted that HRSA has developed a

strategic plan for dealing with disparities in

health care, but although the plan sets forth

strategies, it lacks detail on specific activities. She 

identified the following as key questions the

agency hopes to answer:

• Are there specific activities and services that

are needed, along with more global actions

like increasing access, to eliminate disparities?

• Is there a sense among participants that a

major investment of new funds will be

necessary? If so, Federal agencies will require

help from the medical, academic, and other

communities to justify this.

• How can providers be encouraged to change

ineffective or harmful behaviors, and what is

the best way to communicate with isolated

rural providers?

• Where do program evaluations fit into the

evidence? Are they considered at all?

• How can patient preferences be better

understood?

• What are the implications of managed care

on the content of care and the delivery of

services?

Lynne Wilcox, M.D., M.P.H., of the Centers for

Disease Control and Prevention (CDC), the

“prevention” agency, noted that the CDC is

involved in two activities that are relevant to the

discussion: public health monitoring/surveillance

and prevention research. A data system that is

currently in use is the Pregnancy Risk

Assessment Monitoring System (PRAMS),

which is designed to capture population-level

information that can be used by programs to

design appropriate responses to maternal and

child health issues within their State. The CDC

also convened a conference last year to examine

maternal morbidity issues and how to capture

this type of information on a population level

and across health systems, to determine the

Nation’s status with regard to maternal

morbidity. To address issues of disparity, Dr.

Wilcox emphasized that not only issues of

mortality must be considered, but also morbidity

(which affects many more women). Some of the

important questions that she raised were:

• What can help explain disparities in

outcomes?

12
• What are appropriate interventions taken in

the context of an individual woman’ lifestyle

(i.e., community-based experience)?

• How may the discussion of maternal health

be bridged with the broader women’s health

discussion?

Dr. Clancy explained that AHRQ will publish

the first ever national report on the quality of

health care in 2003. She noted that the Agency

will have to arrive at some consensus regarding

quality measures before then, possibly by looking

into mechanisms for bringing together

practitioners and public health experts to

develop quality indicators for high-priority

conditions. She also raised the following

questions that are of importance to AHRQ:

• Where does investigator-initiated research fit

into the forthcoming agenda? AHRQ needs

guidance from professional organizations on

how to advertise maternal health services

research opportunities to the clinical

community in order to build the talent for

carrying out maternal health services research.

• Why do disparities in maternal health care

exist, and what is the reason(s) for those

disparities?

• What errors occur in maternal health, and

what are the possible strategies to reduce

those errors?

Sumner Yaffe, M.D., of the National Institute of

Child Health and Human Development

(NICHD), which the National Institutes of

Health component dedicated to maternal and

neonatal research, noted that NICHD has two

broad-based ongoing efforts in the area of

maternal health: studying the epidemiology of

birth defects and studying the molecular

mechanisms underlying the detection of birth

defects. Dr. Yaffe emphasized that unless basic

biological mechanisms of disease are well

understood, any other data will not be

particularly useful on their own. He highlighted

the following ongoing and future activities of

NICHD that are related to maternal and

neonatal health care:

• NICHD funds 13 centers, as part of its

Maternal-Fetal Medicine Network, to study

various factors involved in preterm delivery.

• The Institute has partnered with the National

Institute of Neurological Disorders and

Stroke (NINDS) to study the beneficial

effects of antenatal magnesium and partnered

in the past with the National Heart, Lung,

and Blood Institute (NHLBI) to study

pediatric asthma.

• NICHD plans to convene two joint

conferences with the Food and Drug

Administration (FDA) to examine what is

known about the 2,000 drugs used during

pregnancy and how these drugs can be

properly studied for efficacy.

Beth Benedict, Dr.P.H., J.D., explained that the

Centers for Medicare & Medicaid Services

(CMS, at the time of this conference the Health

Care Financing Administration [HCFA]), unlike

many of its sister agencies, directs the majority of

its research funds and efforts in response to

Congressional mandates. Dr. Benedict noted

that CMS does not offer grants but primarily

participates in cooperative agreements and

contracts. The agency does, however, have a very

strong intramural research group that works with

other agencies on a women’s health research

agenda. CMS relies on other agencies and the

private sector to move research initiatives

forward. 

Within CMS, there is a Center for State

Medicaid Operations (which handles policies,

demonstrations, and waivers) and a separate

Office of Information Systems (which handles

Medicaid data). CMS has already begun to

convert Medicaid data files into research-ready

formats.

Christine Schmidt, M.P.A., of the Office of the

Assistant Secretary for Planning and Evaluation

(OASPE) noted a number of similarities between

the issues discussed at this meeting and other

policy areas that OASPE is involved in. Ms.

Schmidt commented that the abundance of

issues and suggestions for research provided at

13
the meeting were indicative of the complexity of

the maternal health care arena. She highlighted

some of the priority questions from the

perspective of OASPE:

• What is the future of e-health and

information technology in general and in

maternal health care?

• What are the strategies for developing quality

indicators?

• What are the topics for data collection, and

what are the best ways to collect data?

• Are there stakeholders not present at the

conference who should have been engaged in

the discussion?

The meeting concluded with a further discussion

of these interests and activities with participants

and with the recognition that future interagency

collaboration will be critical in developing a

maternal health research agenda capable of

enhancing the knowledge base and moving it

forward.

Conclusion

In an effort to develop a conceptual framework

for the next generation of research on the

quality, content, and use of maternal health care

services, experts from various disciplines and

representatives from five DHHS agencies

identified research gaps and priorities for

research.

A call to develop a rigorous science knowledge

base and to enhance the research infrastructure

resonated throughout the discussion. The panel

identified a rich array of priorities. It is hoped

that with continued dedicated effort these

recommendations will lay the groundwork for

the next generation of research on maternal

health.

Recommendations

Following is a categorized, cumulative list of

research priorities in maternal health as

identified by conference participants.

Content of Maternal Health Care

• Define the objectives of maternal health care

services in relation to a range of specific

outcomes. 

• Expand research on the impact of prenatal

care to alternative outcomes beyond preterm

delivery and low birthweight (e.g., maternal,

perinatal, infant, and child mortality and

morbidity, health behaviors, use of health care

services).

• Disentangle which specific content of care

components within comprehensive prenatal

care packages may be beneficial for targeted

outcomes. Advance the use of randomized

controlled trials for assessing the impact of

these components.

• Examine the recommendations of the Expert

Panel on Content of Prenatal Care to

determine which prenatal care interventions

are supported with adequate evidence and

which unproven interventions will require

further research.

• Reframe health care services to improve birth

outcomes from an exclusive focus on prenatal

care to a continuum of care starting at

preconception through menopause, and fund

more research on the full spectrum of

women’s experiences with reproductive health

services.

• Study the impact of reproductive health

management during the continuum of

maternal health care, focusing not only on

the index pregnancy but also on subsequent

pregnancies to determine if specific types of

interventions have an impact on overall

reproductive health.

Quality of Maternal Health Care

• Perform systematic evaluations of guidelines

or proposed indicators and define optimal

management and expected outcomes.

• Foster efforts to periodically evaluate

proposed prenatal care guidelines and

standards.

14
• Develop indicators across the continuum of

care and across all provider levels.

• Support networks and collaboration to foster

sharing of data and resources, perform

multimethod research design, and

disseminate findings.

• Identify the most effective communication

and education practices for maternal health,

and study how physician-patient

communication affects satisfaction and other

outcomes in different types of settings.

• Develop potential quality indicators for

conditions or services specific to maternal

health care.

• Develop and validate new methods for the

measurement of quality in maternal health

care, to include optimal outcomes, impact on

subsequent pregnancies, and unconventional

outcomes (e.g., decreased morbidity and

developmental handicaps).

• Examine how the coordination of obstetrical

and primary care in different types of

organizations affects quality of care.

• Expand research on the adequacy of prenatal

care use, including improving the current

definition and measurement of adequate use,

exploring normal use patterns, and defining

adequate use for high-risk women.

• Understand patient variation (e.g., attitudes,

preferences, interpretation of informed

consent), and develop tools to integrate

patient satisfaction and expectations in

measuring quality.

• Explore the quality of maternal health care

services from women’s perspectives by

simultaneously collecting quality/service data

from both patients and their providers to

identify differences in perspectives.

• Create mechanisms and tools for providers

that promote adherence to and use of

standards.

Disparities in Access, Use, and Delivery

of Services

• Expand research to explore the varying

impact of prenatal care on diverse

populations as defined by medical,

demographic, cultural, and socioeconomic

characteristics, and use multi-level statistical

modeling techniques to determine how each

of these factors independently affects

perinatal outcomes.

• Develop methods to find variations or

“pockets” of high rates of adverse outcomes,

researching the reasons for the concentrated

poor outcomes and evaluating targeted

interventions to reduce the high rates.

• Investigate the consequences on women’s

maternal health of being born and raised in

communities segregated on the basis of

socioeconomic status, race, and/or ethnicity.

• Examine whether there are racial and ethnic

disparities in the advice, content, or quality of

care provided by health care professionals and

how to enhance cultural sensitivity among

providers.

• Identify factors that drive higher rates of

prematurity and other adverse outcomes in

black women.

• Identify and measure how structural

phenomena like social, economic, and power

inequalities (e.g., racism) directly influence

health outcomes.

• Examine the relationship between social

determinants and population-level

determinants in preterm delivery.

• Examine social, biological, economic, and

environmental contributors to racial and

ethnic disparities in maternal and infant

outcomes.

• Examine the various barriers that keep

women from entering systems of care.

15
Intervention Models

• Focus on the social determinants of maternal

health, including screening and interventions

for domestic violence and substance abuse.

• Develop better interventions (and evaluations

of interventions) for multifaceted problems

(e.g., behavioral, social, biological, cultural)

arising in a diversity of communities.

• Examine what influences women’s health

knowledge and behaviors (e.g., where they get

their information) and identify the types of

care different groups of women prefer.

• Research the impact of social marketing

strategies (e.g., talk shows, soap operas) on

various behaviors.

• Improve the training of alternative types of

providers (e.g., nurses, midwives) to provide

care to women.

Data and Information Needs

• Standardize key data elements, measures,

definitions, and fields.

• Develop demonstrations of information

systems for health services research at the

local, regional, and national levels to

determine the feasibility and barriers to

implementing such systems.

• Initiate a second Collaborative Perinatal

Study that would gather obstetric and

pediatric information from selected hospitals

across the country.

• Develop a primary clinical information

database linked to secondary data (e.g.,

administrative data, managed care ambulatory

data).

• Use Medicaid data to study the role of

Medicaid in family planning and abortion

services.

• Validate existing data and clinical data

systems to determine whether their quality is

sufficient for use in research.

• Collect better data via vital records,

longitudinal studies on prenatal care, and

other services to women in a way that helps

to explain and quantify population risk.

• Improve data quality for monitoring and

surveillance, including improved reporting.

• Provide resources for a standardized clinical

database for the continuum of reproductive

health to link with outcomes, financial, and

registry databases and examine the costeffectiveness (and other implications) of an

electronic medical record.

• Expand the medical component of the

national standard birth certificate, fetal death

certificate, and infant and maternal death

certificates, making them electronically

available. Teach institutions to use these data

to establish benchmarks.

• Develop and evaluate measurement tools and

monitoring systems for maternal health,

maternal outcomes, and health services

support.

• Develop and systematically validate practice

guidelines across all area of women’s lives for

use by internists, family practitioners, and

obstetricians.

• Develop prenatal care guidelines for high-risk

and vulnerable populations.

• Observe how data elements are linked to

outcomes by studying centers of practice that

use computerized systems incorporating

ACOG standards for measuring quality of

care.

• Initiate a demonstration project to collect

primary data based on a minimum data set

into a clinical information system.

• Develop national normative data of sentinel

events or rate-based indicators that have

already been described and stratified by age

and race/ethnicity and use these to develop a

consensus for standardized measures for casemix adjustment.

• Combine data into a repository of clinical

and administrative data and use the data to

develop a methodology to link the structureprocess variables to outcomes of interest.

16
Translating Research into Practice

• Support research and create a culture,

through education, where policymakers,

providers, payers, patients, and legislators

have an understanding and appreciation of

the value of evidence-based practice.

• Develop a process for periodically revisiting

the evidence and a mechanism for

disseminating what is known about both

effective and ineffective interventions.

• Require that grant applications include a

proposed plan for the dissemination of

research findings, and provide funding for

such dissemination activities.

• Determine the appropriate methodological

approaches to conducting dissemination

research.

• Develop stronger interagency communication

and cooperation, and work with the private

sector where cooperation could lead to better

initial designs for studies, analyses, and

applications.

• Promote the concept of a virtual knowledge

base in maternal health which posts (possibly

on the Internet) findings as they are

published, as well as standards, guidelines,

and results of consensus conferences.

• Coordinate and regularly update best

practices by linking and synthesizing

information from ACOG, AHRQ, HRSA,

and CMS.

Training

• Develop a mechanism for training the next

generation of maternal health clinical

scientists to conduct health services research.

References

Alexander GR, Howell E. Preventing preterm

birth and increasing access to prenatal care: Two

important but distinct national goals. Am J

Prevent Med 1997; 13(4): 290-1.

American College of Obstetricians and

Gynecologists: Standards for ObstetricGynecologic Services. Chicago: ACOG, 1974.

Brown SS, editor. Prenatal care. Reaching

mothers, reaching infants. Committee to Study

Outreach for Prenatal Care, Institute of

Medicine. Washington: National Academy Press;

1988.

Chassin MR, Galvin RW. The urgent need to

improve health care quality. Institute of

Medicine National Roundtable on Health Care

Quality. JAMA 1998 Sep 16; 280(11):1000-5.

Committee to Study the Prevention of Low

Birth Weight, Institute of Medicine. Preventing

low birth weight. Washington: National

Academy Press; 1985.

Jack BW, Culpepper L. Prenatal care. J Am

Board Fam Pract 1990; 3(3):228-9.

Kessner DM, Singer J, Kalk CE, Schlesinger ER.

Infant death: An analysis by maternal risk and

health care. In: Contrasts in health status.

Washington: National Academy Press; 1973.

Patient Outcomes Research Team. Low

Birthweight in Minority and High-Risk Women

(contract no. 290-92-0055). AHCPR

Publication No. 98-N005. Rockville, MD:

Agency for Healthcare Research and Quality;

1998.

Smedley BD, Syme SL, editors. Promoting

health: Intervention strategies from social and

behavioral research. Washington: National

Academy Press; 2001.

17

Appendix A. Improving Maternal Health Care:The Next

Generation of Research on Quality, Content, and Use of

Services

U.S. Department of Health and Human Services

Office of the Assistant Secretary for Planning and Evaluation

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention

Health Resources and Services Administration

National Institute of Child Health and Human Development

September 18-19, 2000

Airlie House Conference Center

Warrenton, VA

Meeting Agenda

Monday, September 18, 2000

10:00 a.m. Welcome and Introductions

Carolina Reyes, Chair

Agency for Healthcare Research and Quality

Panel Members

10:30 a.m. Opening Remarks: Issues and Challenges

Christine Schmidt

Office of the Assistant Secretary for Planning and Evaluation

Lisa Simpson 

Agency for Healthcare Research and Quality

10:50 a.m. Overview: Are We Ready to Assess the Content of Prenatal Care?

Linking prenatal care to outcomes

Assessing use of prenatal care services

Milton Kotelchuck

School of Public Health, University of North Carolina 

Greg Alexander*

School of Public Health, University of Alabama at Birmingham

Panel Discussion

*Dr. Alexander was unable to attend. His paper was presented by Milton Kotelchuck.

19
Monday, September 18, 2000 (Continued)

12:00 p.m. Lunch

Keynote: A National Perspective on Maternal Health

Margaret Hamburg

Assistant Secretary for Planning and Evaluation 

1:30 p.m. Pre-term Birth: Next steps after the LBW Patient Outcomes 

Research Team Study

Robert Goldenberg

University of Alabama at Birmingham 

School of Medicine

Panel Discussion

2:40 p.m. A Critical Reexamination of Models of Intervention in

Perinatal and Maternal Health

Vijaya Hogan

Centers for Disease Control and Prevention

Panel Discussion

4:00 p.m. Translating Research Into Practice Focusing on Priority Populations: 

Health Care Outcomes and Effectiveness

Carolyn Clancy

Agency for Healthcare Research and Quality

Panel Discussion

5:15 p.m. Next Steps for the Panel

Carolina Reyes

Agency for Healthcare Research and Quality

20
Tuesday, September 19, 2000

8:00 a.m. Assessing Maternal Quality of Care

Definitions and Measures of Quality of Care

Kimberly Gregory

Cedars-Sinai Medical Center/UCLA

Panel Discussion

9:00 a.m. What Have We Missed?

9:30 a.m. Where Next? Priorities for the Next Generation of Research on

Maternal Health Care Services

Panel Discussion on Content and Quality Issues

1:00 p.m. Research Priorities Continued

Panel Discussion on Access, Cost Benefit and Use of Services 

2:00-3:30 p.m. Speed Planning: Can We Get Started? 

An Action Plan in Ninety Minutes 

Priorities, Strategies and Partnerships

Dialogue with Senior DHHS Officials

Doris Barnette, HRSA

Christine Schmidt, OASPE

Lisa Simpson, AHRQ

Lynne Wilcox, CDC

Sumner Yaffe, NICHD

Panel Experts

3:30 p.m. Closing

21

23

Appendix B. List of Participants

Improving Maternal Health Care:The Next Generation of

Research on Quality, Content, and Use of Services

September 18-19, 2000

Airlie House

Warrenton, VA

Speakers

Carolyn Clancy, M.D.

Director

Center for Outcomes and Effectiveness Research

Agency for Healthcare Research and Quality

Robert Goldenberg, M.D.

Charles E. Flowers Professor

Department of Obstetrics and Gynecology

University of Alabama at Birmingham

Kimberly Gregory, M.D., M.P.H.

Director of Women's Health Policy

Department of Obstetrics and Gynecology

Cedars-Sinai Medical Center

Margaret Hamburg, M.D.

Assistant Secretary for Planning and Evaluation

U. S. Department of Health and Human Services

Vijaya Hogan, Dr.P.H.

Lead Epidemiologist, Pre-Term Delivery Section

Pregnancy and Infant Health Branch

Division of Reproductive Health 

National Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control and Prevention

Milton Kotelchuck, Ph.D., M.P.H.

Professor

Maternal and Child Health

Boston University School of Public Health

Carolina Reyes, M.D.

Assistant Professor, University of 

California, Los Angeles

Division of Maternal-Fetal Medicine

Department of Obstetrics and Gynecology

Cedars-Sinai Medical Center

Christine Schmidt, M.P.A.

Deputy to the Deputy Assistant Secretary for Health

Policy

Office of the Assistant Secretary for Planning and

Evaluation

U. S. Department of Health and Human Services

Joanna Siegel, Sc.D.

Director

Research Initiative on Clinical Economics

Center for Outcomes and Effectiveness Research

Agency for Healthcare Research and Quality

Lisa Simpson, M.B., B.Ch., F.A.A.P.

Deputy Director

Agency for Healthcare Research and Quality

Participants

Doris Barnette, M.S.W.

Principal Advisor to the Administrator

Health Resources and Services Administration

Beth Benedict, Dr.P.H., J.D.

Social Service Research Analyst

Division of Beneficiary Studies

Health Care Financing Administration

Cindy Berg, M.D., M.P.H.

Medical Epidemiologist

Division of Reproductive Health

National Center for Chronic Disease

Prevention and Health Promotion

Centers for Disease Control and Prevention

Karla Damus, R.N., Ph.D., M.S.P.H. 

Senior Research Associate

Office of the Medical Director

National March of Dimes

William Freeman, M.D., M.P.H. 

Director

Research Programs

Indian Health Service

Fredric Frigoletto, Jr., M.D.

Chief of Obstetrics

Department of Obstetrics and Gynecology

Massachusetts General Hospital

Marcy Gross

Senior Advisor on Women's Health

Agency for Healthcare Research and Quality
24

Embry Howell, Ph.D., M.S.P.H.

Vice President

Health Division

Mathematica Policy Research, Inc.

Jeffrey King, M.D.

Director of Maternal-Fetal Medicine

Department of Obstetrics and Gynecology

Wright State University School of Medicine

Michael Kogan, Ph.D.

Director

Office of Data and Information Management

Maternal and Child Health Bureau

Health Resources and Services Administration

Gontran Lamberty, Dr.P.H.

Chief, Research Branch

Division of Research, Training and Education

Maternal and Child Health Bureau

Health Resources and Services Administration

Jean Lawrence, Sc.D., M.P.H., M.S.S.A. 

Senior Investigator

Research and Evaluation

Kaiser Permanente, Southern California

Charles Lockwood, M.D.

Stanley H. Kaplan Professor and Chair

Department of Obstetrics and Gynecology

New York University School of Medicine

Alan Peaceman, M.D.

Associate Professor

Department of Obstetrics and Gynecology

Northwestern University Medical School

Andrea Pernack, M.P.H.

Health Policy Analyst

Office of the Assistant Secretary for Planning and

Evaluation

U.S. Department of Health and Human Services

Caroline Taplin

Senior Policy Analyst

Office of the Assistant Secretary for Planning and

Evaluation

U.S. Department of Health and Human Services

Judith Weiss, Sc.D.

Co-Director

Maternal Mortality and Morbidity Project

Bureau of Family and Community Health

Massachusetts Department of Health

Lynne Wilcox, M.D., M.P.H.

Director 

Division of Reproductive Health

National Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control and Prevention

Sumner Yaffe, M.D.

Special Assistant to the Director

National Institute of Child Health and Human

Development

National Institutes of Health

Observers

Jeffrey Coben, M.D.

Director

Center for Violence and Injury Control

Allegheny General Hospital

Steven Fox, M.D., M.P.H., M.S.

Medical Officer

Center for Outcomes and Effectiveness Research

Agency for Healthcare Research and Quality

Linda Franklin

Program Analyst (Women's Health)

Agency for Healthcare Research and Quality

Henrietta Hubbard, R.N., M.P.H. 

Special Assistant to the Director

Center for Outcomes and Effectiveness Research

Agency for Healthcare Research and Quality

Kerry Paige Nesseler, R.N., M.S.

Deputy Associate Administrator for Programs

Maternal and Child Health Bureau

Health Resources and Services Administration

Diane Rowley, M.D., M.P.H.

Associate Director for Science

National Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control and Prevention

Eileen Salinsky, M.B.A.

Director

Division of Public Health Policy

Office of the Assistant Secretary for Planning and

Evaluation

U.S. Department of Health and Human Services

Peter van Dyck, M.D., M.P.H.

Associate Administrator

Health Resources and Services Administration

Facilitator

Lawrence Bartlett, Ph.D.

Director

Health Systems Research, Inc.
25

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Prenatal Care Barriersfor Low and ModerateIncome Women

Paula Braveman National Library of

Medicine 

University ofCalifornia SanFrancisco

Agency forHealthcare Researchand Quality(AHRQ)

Study access to prenatal care inCalifornia women (with income below250% of poverty in different insurance& ethnic groups) following expansionsof poverty level and demographicchange due to immigration. Determinethe extent to which personal andsystems barriers act alone or in concertwith financial barriers to deter adequateuse of prenatal care.

Appendix C. Prenatal Care Research Sponsored by DHHS, September 2000

The following matrix is a compendium of recent prenatal care research sponsored by agencies within the Department of Health and Human Services

(DHHS). It was current as of September 2000. This list was compiled from various resources from DHHS agencies (e.g., agency research plans,compilations of agency research as provided through Internet resources, informal surveys within agencies, additional information provided by agencystaff). Although we attempted to be as comprehensive as possible, we expect that there are additional research projects that are not included in this chart.The research projects are sorted by sponsoring agency.

Low Birthweight inMinority Women andHigh-Risk Women

Robert L.Goldenberg

AHRQ University of

Alabama,BirminghamAlbert EinsteinCollege of Medicine 

AHRQ Advance the scientific knowledge base

about variation in and effectiveness ofobstetrical practices and otherinterventions aimed at the preventionof LBW and negative sequelae.
26

Medicaid ManagedCare and the OregonHealth Plan 

Alison Buist National Library of

Medicine

Johns HopkinsUniversity

AHRQ Identify and explore the extent to

which prenatal care for low-incomewomen has changed in Oregon as aresult of changes followingimplementation of the Oregon HealthPlan (OHP), which requires thatMedicaid beneficiaries enroll inmanaged care. 

Childbirth PORT(Patient OutcomesResearch Team) 

Emmett Keeler AHRQ RAND AHRQ Examine use and outcomes of cesarean

delivery versus alternatives, includingoxytocin, trial of labor, and normal andassisted vaginal delivery. 

Developing Culturally

and LinguisticallyAppropriate PrenatalCare Education

Virginia Gonzales National Library of

Medicine 

University ofWashington 

AHRQ Improve prenatal care for

Spanish-speaking women in managedcare populations by increasing theiraccess to effective prenatal healtheducation and develop generalguidelines for culturally andlinguistically appropriate healtheducation materials. 

Evaluating a DecisionTool for PrenatalTesting 

MiriamKuppermann 

National Library ofMedicine

University ofCalifornia, SanFrancisco 

AHRQ Evaluate computerized prenatal testing

decision-assisting tool for makingchoices about diagnostic testing for fetalchromosomal abnormalities. 

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective
27

Pregnancy RiskAssessment MonitoringSystem (PRAMS):numerous studies 

Mary

Rogers, Mary

Lyn Gaffield,Suzanne Zane 

Centers for DiseaseControl andPrevention (CDC),Division ofReproductiveHealth (DRH)Survey 

State HealthDepartments,CDC/DRH 

State HealthDepartments,CDC/DRH 

Recent focus areas of study at CDCinclude:-content of prenatal care-characteristics of women who do notreceive ACOG-recommended messages-barriers to oral healthcare services-effects of welfare reform on prenatalcare use -effects of intimate partner violence ondelayed entry into prenatal care-socioeconomic disparity in use ofprenatal care-factors related to early entry intoprenatal care.

Title Investigator

Source

PerformingOrganization

SponsoringAgency Objective

Surveillance forPrenatal Care amongNative AmericanPopulations 

Health depts ofvarious NativeAmerican Tribes;technical assistancefrom CDC/ DRH 

DRH Survey 

Native Americantribes 

Indian HealthService 

Conduct household based surveys: faceto face interviews of American Indianwomen and men 18 years of age andolder, including questions on prenatalcare. 

Maternal Infant RapidIntervention atDelivery

CDC, DRHSurvey

CDC/DRH De

velop, implement and evaluate

strategies to provide integratedreproductive health services to womenwho present in labor with no prenatalcare. Includes counseling oncontraception and reproductivedecisionmaking, early enrollment inprenatal care for future pregnancies,screening and treatment for STDs,provision of barrier methods ofcontraception; and for HIV-positivewomen, provision of HIV-relatedmedical care. 
28

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

SPEAC: Preterm BirthAmong Inner CityWomen: BacterialVaginosis, Stressors andRace

Virginia Rauh,Jennifer Culhane 

DRH Survey Health Federation

of Philadelphia

CDC/DRH Conduct a cross-sectional study of the

prevalence of bacterial vaginosis (BV)and stress and determine other factorsthat are associated with these; use aprospective cohort design to study theassociation among BV, stressors, andpreterm delivery. 

Maternal Effects ofTreatment for BacterialVaginosis 

Jane Hitti DRH Survey University of

Washington

CDC/DRH Conduct a prospective, randomized

trial of oral vs. intravaginalmetronidazole for the treatment ofbacterial vaginosis among pregnantwomen at low risk for preterm delivery.Study side-effect profiles of eachadministration mode, compare theefficacy, and compare the effects onreduction of preterm delivery. 

Harlem BirthRight Leith Mullings,

Alaka Wali

DRH Survey New York Urban

League

CDC/DRH Document the contexts of pregnancy

among African American women inCentral Harlem, New York City anddisseminate this information to otherpublic health and medical professionals. 

Reproductive HealthStatus of IncarceratedWomen in the State ofGeorgia 

Lori deRavello,Dabo Brantley

DRH Survey CDC/DRH CDC/DRH;

GeorgiaDepartment ofCorrections;Georgia Division ofPublic Health 

Conduct a retrospective studycomparing birth outcomes amongpregnant women incarcerated inGeorgia for 1998-99. 
29

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Healthy AfricanAmerican Families(HAAF)

Loretta Jones DRH Survey Drew University CDC/DRH Define the context of pregnancy among

African-American women and theirfamilies in Los Angeles. Qualitativeresearch was conducted to understandthe roles of health care, stress, familyrelationships, spirituality, nutrition, andwork during pregnancy and to developcommunity and family asset models forprevention and intervention activities.

An Analysis of the Useof Urine Cotinine as aMeasure of TobaccoExposure in PregnantWomen

Lucinda England DRH Survey CDC/DRH CDC/DRH Evaluate the relationship between

reported cigarette consumption andurine cotinine and the relationshipbetween exposure and birthweight byanalyzing Smoking Cessation inPregnancy (SCIP) data. 

Tobacco Exposure andBirthweight at Term

Lucinda England DRH Survey CDC/DRH CDC/ DRH Analyze Smoking Cessation in

Pregnancy (SCIP) data to evaluateeffects of smoking reduction onbirthweight in term infants. 

Multi-SiteCollaboration onInfection DuringPregnancy 

Sabina Cauci DRH Survey CDC/DRH CDC/DRH Conduct a multi-center collaborative

study to assess the effect of IgA onlevels of preterm delivery, particularlyits effect in women with diagnosedbacterial vaginosis. 

Social Networks Project Michelle Kelley DRH Survey University of Illinois

at ChicagoPrevention ResearchCenter

CDC/DRH Through the use of communityuniversity partnered research, document

and understand the impact of socialnetworks on access to prenatal care. 
30

Title Investigator

Source

PerformingOrganization

SponsoringAgency

Objective

In

vestigation of Factors

Associated withMaternal Mortality 

Stacy Geller DRH Survey

University of Illinoisat Chicago

CDC/DRH Evaluate prenatal and intrapartum

quality of care and effect on survivalamong women with severe pregnancymorbidity. 

Maternal MorbidityCaused by InfectiousAgents 

Linda Cushman DRH Survey Columbia

University 

CDC/DRH 

Study the extent of maternal morbiditydue to infectious agents among lowincome, predominantly Hispanic andAfrican American, clinic patients at alarge urban medical center; identifyracial, ethnic, and sociodemographicdifferences in infection-related maternalmorbidity; share findings withpractitioners and community groups todevelop culturally sensitive preventionstrategies. 

EvaluationDemonstrationImproving Access toCare for PregnantSubstance Abusers 

Embry Howell

National Library ofMedicine 

Mathematica PolicyResearch, Inc 

Centers for Medicare& Medicaid Services(CMS), (formerlyHealth CareFinancingAdministration,HCFA) 

Evaluate a demonstration to improveMedicaid access to care for pregnantsubstance abusers that is beingimplemented in five States: Maryland,Massachusetts, New York, SouthCarolina, and Washington State.

Uterine RuptureAssociated with Trialsof Labor for VaginalBirth after Cesarean

Section (VBAC)

Judy Weiss, LindaBartlett

DRH Survey

Massachusetts Dept.of Health,CDC/DRH 

Massachusetts Dept.of Health,CDC/DRH

Study uterine rupture rates for 1990-1997, describe the characteristics of thewomen who have ruptured uteriassociated with a trial of labor forVBAC, explore the feasibility ofpredicting which women will havemore severe ruptures and describe theoutcomes of the women and theirinfants. 
31

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Satisfaction with andUse of Prenatal Care 

Arden Handler National Library of

Medicine 

University of Illinois HRSA/MCHB Determine whether the characteristics

of prenatal care are related to a woman’ssatisfaction (independent of thewoman’s personal characteristics).Hypothesize that relationship betweencare characteristics and satisfaction donot differ for black Medicaid andnon-Medicaid recipients. 

Maternal Birthweightand ReproductiveOutcomes 

Irvin Emanuel National Library of

Medicine 

University ofWashington 

HRSA/MCHB Investigate the intergenerational

relationships between the mother’sbirthweight and other maternal factorswith several complications of pregnancyand birth outcomes. 

Birth RecordEnhancements of theNew York StateMedicaid ManagedCare Encounter System 

Patrick Roohan National Library of

Medicine 

New York StateDepartment ofHealth 

HRSA/MCHB Monitor and assess the effects of the

State’s mandatory Medicaid ManagedCare (MMC) program on MCH goalsand objectives by incorporating birthrecord data and prenatal and birthoutcome reports into the New YorkState Medicaid Encounter Data System(MEDS).
32

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Honoring OurChildren 

Dale Wolf National Library of

Medicine 

Great LakesInter-TribalCouncil, Inc.(GLITC) 

HRSA/MCHB Improve the health and well being of

Native American children includingassisting tribal partners with theirefforts to reduce infant mortality and toincrease the utilization of prenatal visitsand well-child care. 

Asthma ObservationalStudy 

MitchDombrowski 

National Instituteof Child Healthand HumanDevelopment(NICHD)Maternal FetalMedicine Units(MFMU) Network 

Wayne StateUniversity 

National Institute ofChild Health andHumanDevelopment(NICHD) &National Heart,Lung, and BloodInstitute (NHLBI)

Assess the relationship betweenmoderate to severe asthma and adverseperinatal outcome, as compared withnon-asthmatic controls. 

Asthma RandomizedClinical Trial 

MitchDombrowski 

NICHD MFMUNetwork 

Wayne StateUniversity 

NICHD & NHLBI Determine whether regular inhaled

beclomethasone for patients withmoderate asthma during pregnancyresults in better asthma control thanoral theophylline. 

Healthy Families in aHealthy Community

Stephen Weeg National Library of

Medicine 

Harms MemorialHospital 

HRSA/MCHB Study a frontier county with a large

population of Hispanic migrant farmworkers and a deficit of health serviceswhere mothers are 47% less likely thanmothers statewide to receive adequateprenatal care. The objective is toincrease the number of women usingadequate prenatal care services to theHealthy People 2000 goal of 90%. 
33

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

BEAM RandomizedClinical Trial 

Dwight Rouse NICHD MFMU

Network 

University ofAlabama atBirmingham 

NICHD &National Institute ofNeurologicalDisorders andStroke (NINDS) 

Determine whether intravenousmagnesium sulfate given to womenremote from term, and for whomdelivery is imminent can reduce the riskof cerebral palsy in their children. 

Bacterial VaginosisRandomized ClinicalTrial 

Chris Carey andMark Klabanoff 

NICHD MFMUNetwork 

NICHD Test whether administration of

metroniadazole to asymptomaticwomen with bacterial vaginosis reducesthe risk of preterm delivery. 

Cesarean RegistryObservational Study 

Mark Landon NICHD MFMU

Network 

Ohio StateUniversity 

NICHD Determine the characteristics of women

undergoing a trial of labor anddetermine the efficacy and safety of atrial of labor; determine cesareandelivery rates by payer and providerstatus and describe complications andfactors influencing outcome in womenundergoing cesarean delivery. 

Cervical UltrasoundObservational Study

John Owens NICHD MFMU

Network 

University ofAlabama atBirmingham

NICHD Assess the relationship between

shortened cervical length before 24weeks gestation and subsequentspontaneous preterm delivery. 

Factor V LeidenObservational Study 

Donna DizonTownson NICHD MFMU Network University of Utah NICHD and Office of Research on

Women’s Health(ORWH) 

Determine the incidence of pregnancyrelated thromboembolism in womencarrying the FVL mutation anddetermine the effects of thromobophiliaon the risk of thromoboembolism. 
34

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

ProgesteroneRandomized ClinicalTrial 

Paul Meis NICHD MFMU

Network 

Wake ForestUniversity 

NICHD Establish whether weekly progesterone

injections for women who haveexperienced a previous spontaneouspreterm delivery reduces the risk ofpreterm birth. 

Trichomonas vaginalisRandomized ClinicalTrial 

Chris Carey andMark Klabanoff 

NICHD MFMUNetwork 

NICHD Test whether administration of

metronidazole to asymptomatic womenwith Trichomonas vaginalis reduces therisk of preterm delivery. 

Repetitive SteroidsRandomized ClinicalTrial 

Ronald Wapner NICHD MFMU

Network 

Thomas JeffersonUniversity 

NICHD Test whether a regimen of weekly

courses of steroids is safe and effectivecompared with the single course. 

Fetal FibronectinRandomized ClinicalTrial 

William Andrews NICHD

MFMU Network 

University ofAlabama atBirmingham 

NICHD Test whether prophylactic antibiotic

therapy administered to women withelevated mid-trimester fetal fibronectindecreases the risk of spontaneouspreterm delivery. 
35

Genetic Asthma Study Mitch

Dombrowski 

NICHD MFMUNetwork 

Wayne StateUniversity 

NICHD Determine whether homozygosity of

specific polymorphisms is associatedwith clinically significant functionalchanges in asthma severity. 

Preeclampsia Prediction Les Myatt and

MenachemMiodovnik 

NICHD MFMUNetwork 

University ofCincinnati 

NICHD Determine whether biochemical or

biophysical markers, individually or incombination, can predict thedevelopment of preeclampsia. 

Mild GestationalDiabetes RandomizedClinical Trial 

Mark Landon NICHD MFMU

Network 

Ohio StateUniversity 

NICHD Determine whether identification and

dietary treatment of women with mildgestational diabetes reduces the risk ofdelivering a large for gestational ageinfant compared with standard care. 

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Antioxidant Trial Jim Roberts NICHD MFMU

Network 

University ofPittsburgh 

NICHD Determine if antioxidant therapy

prevents preeclampsia. 

Fetal Pulse Oximetry Steven Bloom NICHD MFMU

Network 

University of TexasSouthwestern 

NICHD Measure the impact of fetal oximetry as

an adjunct to conventional electronicfetal heart rate monitoring on theoverall cesarean delivery rate. 

Smoking Cessation Robert Goldenberg NICHD MFMU

Network 

University ofAlabama atBirmingham 

NICHD Determine whether smoking cessation

therapy results in increased birthweightand/or an increased rate in smokingcessation during pregnancy. 

Prenatal Care Use andAdverse HealthBehaviors DuringPregnancy 

L. A. Maiman National Library of

Medicine 

NICHD NICHD Study behavioral and social support

interventions to improve early entry toprenatal care and adherence to the visitschedule and decrease adverse healthbehaviors during pregnancy. 
36

Title Investigator Source

PerformingOrganization

SponsoringAgency Objective

Cost-Effectiveness ofPerinatal SubstanceAbuse Programs 

Jerry Cromwell National Library of

Medicine 

Center for HealthEconomics Research

National Instituteon Drug Abuse(NIDA) 

Identify and quantify a wider range ofcosts and assess the extent to whichalternative treatments are effective inreducing those costs. 

Drug Treatment andCare During Pregnancyin HIV-PositiveWomen

Stephen Crystal National Library of

Medicine 

State University ofNew Jersey, NewBrunswick 

NIDA Study the impact of drug use, drug

abuse, treatment, psychiatriccomorbidity, characteristics ofHIV-related health care, and otherfactors on access to prenatal care andadherence to recommendations toprevent vertical transmission of HIV. 

Use of Health Care byDrug-Using PregnantWomen 

Donna Strobino National Library of

Medicine 

Johns HopkinsUniversity 

NIDA Describe the prenatal and other health

care use of drug-abusing pregnantwomen and examine the factors that arerelated to the Health Belief Model. 

Perinatal Assessment,Referral, and ServiceUse 

Dorie Klein National Library of

Medicine 

WesternConsortium forPublic Health 

NIDA Examine the formulation and

implementation of California’s 1990law (SB 2669) mandating protocols foridentifying and intervening in cases ofprenatal substance use or exposure.