LOWER RATES OF LOW BIRTHWEIGHT AND PRETERM BIRTHS: DISCUSSION
The BIH intervention program contributed to the observed lower rates of very preterm and VLBW outcomes. The content and characteristics of the intervention are important to the discussion of study results. The BIH intervention program was funded by the California legislature in 1989 to improve the health of African-American women, infants, and children, thereby reducing African-American infant mortality. The guiding principles for the program were: participant self-empowerment, community involvement and ownership of the response to the problem, and partnership among the State Health Department, Maternal and Child Health Branch, local BIH projects, and aca-demia. It was implemented in the 16 health jurisdictions (17 separate sites in cities and counties) throughout the state where 97% of the African-American live births and infant deaths occurred.
The BIH Program did not provide prenatal care but consistently enabled and supported clients with prenatal care entry and continuance. Therefore, BIH interventions were complementary to usual prenatal care. The program is similar to previous interventions because it uses some of the same structural elements: augmented services during the prenatal period, services designed specifically for African-American women, outreach and tracking, office-based services enhanced by telephone and in-home contacts, and preservice risk screening. There is, however, considerable uniqueness due to common infrastructure development and support, a focus on community-based strategies for health education, behavior change and risk reduction, and the design of program elements into a relational whole to create models of best practice. canadian pharmacy viagra
Four best practice models comprised the program intervention. The Prenatal Care Outreach model utilizes community health outreach workers to conduct intensive outreach to identify and link pregnant African-American women to BIH, general prenatal care, and other appropriate services. It also deals with client tracking. The Case Management model utilizes public health nurses to conduct home visits for the purpose of assessment, referrals, provision and coordination of services, monitoring, and follow-up. The Social Support and Empowerment model provides social support to pregnant and parenting women. It assists women to identify their own strengths, and to utilize health and related resources to improve their lives. Finally, in order to foster the active involvement of fathers in the lives of their infants, the Role of Men model was developed. Fathers are taught fatherhood and parenting skills, personal and legal rights, options for completion of education, and vocational and job skills.
Each site implemented the Prenatal Outreach model and at least one more model, based on the results of their local needs assessment. Regardless of the models implemented, the unifying link between them was the engagement of community support for the BIH mission. This buy-in and partnership created an environment in which positive changes made by the individual woman were recognized and supported by the community overall. Community organizations and agencies—such as beauty shops and barber shops, retail stores, churches, and service clubs—were recruited to participate in a “Healthy African-American babies” network. The network also contributed to the dissemination of knowledge and skills about healthy reproduction and parenting.
The study results did not find statistically significant differences between the LBW and PTB outcomes of BIH participants and the outcomes of the comparison group (Tables 4 and 5), however, because there is a consistent downward trend observed in the rates of VLBW and very PTB among the California BIH participants. The rate of VLBW for BIH women is 63% of that for comparison women, and the PTB rate for BIH women is 81% of the rate for the comparison group. The effect appears to be a redistribution of newborns out of the VLBW and VPT categories into the next highest BW category. The occurrence of the observed effect in both LBW and PTB adds to the weight of evidence for these findings.
The data on the four sites selected out of the 17 total projects sites showing BIH LBW rates lower than the year-2000 objective (Figure 1), suggest that these sites had programmatic experiences that were unique among the sites. However, their results do not appear to be explained by differential client risk factors associated with good outcomes (Tables 2 and 3). These results also point to the fact that there are lessons to be learned across sites in the BIH Program.
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Though the findings are not statistically significant, they should be considered in light of the higher-risk profile of the women retained by the BIH Program (Tables 1-3). Additionally, though 99% of BIH women received some prenatal care, their prenatal care initiation profile showed that they began care later than the comparison group. BIH women were more likely to initiate prenatal care in the second or third trimester of pregnancy.
In this study, the African-American infant outcomes most responsive to the targeted BIH intervention were VLBW and very PTB. These results are similar to those of Norbeck, Zimmer-Gembeck, Korenbrot and Moore. They support the need for further study of the design and implementation of model interventions designed with an understanding of the African-American culture as it relates to health. More knowledge is needed about motivators of health behavior and about which strategies are most likely to effect change in the existing reproductive and infant health disparities. These would be interventions that merge science (perinatal epidemiology, standardized validated intervention models, and data and information sciences), and cultural competence (African-American values, beliefs, and motivations). Furthermore, the importance of place—the community-based context for interventions targeted at African Americans—is a cross-cutting issue to be examined. Finally, the risk-screening tool developed especially for African-American women identifies some unique psychosocial risk factors, which need further study. Use of the tool in future studies will enhance the assessment of its validity among African Americans in other geographic locations and may lead to increased understanding of how they interact with reproductive outcomes.
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The limitations of the study were: a differential drop-out rate for women with lower risk and the fact that BIH participants were not removed from the Medi-Cal comparison group data. Both of these limitations would tend to suppress the effect of the BIH intervention. In conclusion, the BIH Program retained high-risk women in care. Most importantly, in spite of that high-risk profile, the program participants show a trend towards better outcomes than women in the ZIP codes overall.