Use of evidence-based models and standardization of prenatal case management programs: What is the practice?

Prenatal case management (PCM) is a community-based, health related service designed to improve birth and early infancy outcomes for high-risk pregnant women. Research on the effectiveness of PCM has yielded mixed results, with authors commenting on inconsistencies in what comprises PCM interventions. These inconsistencies could result from lack of theory, which in turn leads to less standard practices. Conversely, more standardized programs ought to be evidence and theory based. Yet, little is known about how or whether PCM programs are theory based or standardized. We sought to address this knowledge gap.

Data available from an ongoing national survey of PCM programs were analyzed. Program directors (n=43) reported on whether their programs had written policies or procedures for each of 10 program aspects, as well as whether they used a theory for their program. Most program directors (n=20, 48%) reported either not using a theory or not knowing what it is. Of programs with a model, most used a mixed model (n=9, 41%), followed by their own program logic model (n=5, 23%), and the professional nurse model (n=4, 18%).

The mean standardization score was 5.0 (s.d.=2.6) of 10. Most programs had written policies for client contact (83%), minimum case manager education (83%) and how long cases are open (73%), and the fewest had policies for maximum caseload size (14%). No significant differences were found between programs with or without a theory on their mean standardization score, but larger programs had more policies (r=.39; p=.04). Lastly, programs using a theory were more likely to have written policies regarding eligibility screening criteria (chi-square=9.2; p=.002) and standardized client education protocols (chi-square=3.1; p=.08).

The lack of a consistent theoretical foundation across PCM programs, along with the low levels of standardization, results in program variability which affects the effectiveness of PCM programs. Larger PCM programs and those that are based in health departments are more likely to have standardized policies and procedures, though the degree of standardization does not appear to be related to any sort of theoretical underpinnings of the programs. Further research is needed to explore the relationship between program standardization and birth outcomes.