Evidence points to structure and staff mix as key for effective case management of pregnant women

Background: Prenatal case management (PCM) is a health-focused service provided to pregnant women who are at medical or social risk for adverse birth outcomes with the intent of assuring a healthy birth and improved neonatal outcomes. PCM is often provided as home visiting to pregnant women. Randomized clinical trials found that the use of registered nurses (RN) only as prenatal case manager resulted in better outcomes for the women. However, only one known national study has sought to describe the manner in which PCM is administratively implemented. This leaves a considerable gap in our understanding of whether administration and structure of this important service for vulnerable, high risk women has an effect on the effectiveness of PCM. Structure of programs encompass the staff mix, standardization of interventions, and relationship to other existing prenatal services.

Research Question: Looking across existing evidence, is there a relationship between PCM effectiveness and staff mix, standardization, or integration with existing prenatal services?

Method: A systematic literature search and review was conducted. In addition, to file drawer and scientific literature database searches, websites of known PCM related programs (i.e., the Nurse Family Partnership) were reviewed for additional or new materials. Public health nursing and maternal and child health listserves were used to solicit unpublished reports and research findings. Studies were excluded if they: (a) did not provide information on any of the interventions used within PCM or did not include PCM as a distinct component of a comprehensive program; (b) did not include at least one maternal health outcome important in pregnancy, a maternal intrapartum or postpartum health outcome, or a neonatal outcome ; or (c) reported only behavioral health outcomes, such as smoking cessation. Cooper (1998) outlined a literature synthesis approach, the vote count method, that is based on a simple count of the number of studies that show significant results for and against the intervention. The vote count method was used.

Findings: Prenatal care utilization and birth outcomes were reported in 42 primary studies published from 1986 through 2006. Most studies failed to report statistical significance on the outcomes of interest, and were of fair quality. Of the 42 studied, 13 (31%) were randomized clinical trials or prospective cohort studies with fair to high quality. There were three quasi-experimental studies, with quality scores of fair and poor quality. The retrospective studies of various designs used Medicaid claims or medical records and vital records data, and tended to be of fair to poor quality.

In nearly two thirds of the studies (n=26, 61%) we were unable to determine the gestational age at which the pregnant women were enrolled into PCM; none of the PCM studies reviewed, enrolled women in their first trimester. The timing of PCM initiation was the only information consistently reported which would allow for an approximation of PCM “dosage”. In 12 of the 16 studies that did report when the woman began PCM, PCM began during the 2nd trimester. PCM had a positive effect on birth weight and LBW rates in 65% of the studies and on PTB and gestational age in 69% of studies. This is consistent with the seven meta-analyses identified and reviewed.

The two structural characteristics commonly reported in articles were the use of a protocol to have standardized interventions across recipients, and whether the PCM was an integral part of prenatal care or a separate, distinct program. The staff mix data revealed that 31% (n=13) of the studies used the RNs only model for PCM. The lay outreach worker only model was used in 9 (21%) studies. The RN only model appears more likely to result in improved neonatal outcomes, whereas the lay outreach work model more likely to result in more prenatal care visits. Of the 8 studies in which PCM was integrated into prenatal care, 6 (75%) had significant positive outcomes for neonates, compared to 8 (42%) of the 19 studies of stand alone, standardized PCM programs with significant neonatal outcomes.

Conclusion: Far greater attention to the structure, staff mix, and organizational context of PCM could improve PCM effectiveness. With the looming nursing shortage, strategies and policies are needed to assure that the most vulnerable of pregnant women receive the strongest interventions from RNs providing PCM.