Well-baby Care Research Articles

Making Time for Well-Baby Care: The Role of Maternal Employment

The American Academy of Pediatrics recommends children receive six well-baby visits between ages 1 month and 1 year, yet by age 14 months less than 10% of infants have received all six visits. Cost sharing under public and private insurance is very low. Low compliance rates despite the low cost of care suggest other factors, such as time costs, may be important. This paper examines the relationship between maternal employment and receipt of well-baby care. The Medical Expenditure Panel Survey contains rich information on use of preventive care, maternal employment, and other economic and non-economic factors that may influence care decisions. Several approaches, including a proxy variable strategy and instrumental variables analysis, are used to attempt to address the potential endogeneity of maternal employment and examine the sensitivity of findings. Findings indicate mothers who work full-time take their children to 0.18 fewer visits (or 9% fewer at the mean) than those who have quit their jobs. Mothers with employer provided paid vacation leave take their children to 0.20 more visits (or 9% more at the mean) than other working mothers. Time appears to be an important factor in determining well-baby care receipt. Policies that extend paid leave to more employed women may improve compliance with preventive care recommendations.

Child growth from birth to 18 months old born after assisted reproductive technology—Results of a national birth cohort study

Background Pregnancy conceived by assisted reproductive technology (ART) carries a higher risk of adverse birth outcomes. So far, there have been very few longitudinal studies of the growth of children born after ART. Objective The purpose of this study was to explore the determinants of growth of children born after ART. Design, setting and participants Using data of Wave I (6 months old) and II (18 months old) of the Taiwan Birth Cohort Study (TBCS), a national sample of 21,248 pairs of mothers and their children were included for analysis, including 366 pairs resulting from ART (1.7%). Methods Data were collected through field interviews with structured questionnaires, and with references to each child's birth certificate and Passport of Well-baby Care. Results Compared to children born with naturally conceived pregnancy, children born after ART had a significantly higher incidences of low birth weight (33.1 vs. 6.9%; p < 0.001) and prematurity (42.1 vs. 11.3%; p < 0.001). Overall children born after ART had a similar trend of growth in body weight from birth to 18 months old, but did not achieve catch-up of body weight by 18 months old. On the other hand, they had a faster growth and evidence of catch-up in both body height and head circumference from 6 months to 18 months old. Stratified by the birth number, for singleton or twin babies, there was no significant difference in most parameters of growth at birth and up to 18 months old between babies born by ART compared with those born through a natural conception. Analysis using generalized estimating equation modeling showed that multiple pregnancy and breastfeeding as well as having the mother herself as the caregiver in daytime through 18 months old are the negative and positive contributing factors, respectively for both growth and the change of growth with time among children born after ART. Conclusion Though exhibiting a higher incidence of low birth weight as well as prematurity, children born with ART enjoyed a similar or faster rate of growth from birth to 18 months old when compared to those children born through naturally conceived pregnancies. While multiple gestation is always a negative contributing factor, continuous breastfeeding and having the mother herself as the caregiver in daytime are positive contributing factors for the growth and/or change of growth for the children born after ART.

Parent Mentoring and Child Anticipatory Guidance with Latino and African American Families

Poor health and developmental outcomes for children are linked to scarcity of economic resources, various barriers in the delivery of health services, and inadequate parenting. To mitigate such adverse effects and address the needs of 50 high-risk, low-income Latino and African American families receiving well-baby care at an urban primary care health center, a collaborative team from the social work, nursing, and education fields piloted a preventive two-year parent mentoring project. The intervention was theoretically anchored in the transactional model of child development. The mentoring practices used an activity-based approach for strengthening child anticipatory guidance and meeting family needs. Thirty-five intervention families completed the project. Compared with a matched community sample, intervention families showed positive statistically significant changes in parent and child outcomes. The discussion addresses the practical benefits of the intervention, limitations of the evaluation design, and implications for collaborative multidisciplinary practice.

The Rourke Baby Record Infant/Child Maintenance Guide: do doctors use it, do they find it useful, and does using it improve their well-baby visit records?

BackgroundThe Rourke Baby Record (RBR) – – is a freely available evidence-based structured form for child health surveillance from zero to five years. Family physicians/general practitioners (FP/GPs) doing office based well-baby care in three Ontario Canada cities (London, Ottawa, and Toronto) were randomly sampled to study the prevalence and utility of the RBR and documentation of well-baby visits.MethodsDatabase with telephone confirmation was conducted to assess the prevalence of use of the RBR.Study Part 1: Questionnaire mailed to a random sample of 100 RBR users. Outcome measures were utility of, helpfulness of, and suggestions for the RBR. Descriptive analysis was employed.Study Part 2: Retrospective chart review of well-baby visits by 38 FP/GPs using student t-tests and factor analysis. Outcome measures were well-baby visit documentation of growth, nutrition, safety issues, developmental milestones, physical examination, and overall comprehensiveness.ResultsThe RBR was used by 78.5% (402/512) of successfully contacted FP/GPs who did well-baby care in these 3 cities.Study Part 1: Questionnaire respondents (N = 41/100) used the RBR in several ways, and found it most helpful for assessing healthy child development, charting/recording the visits, managing time effectively, addressing parent concerns, identifying health problems, and identifying high risk situations. The RBR was seen to be least helpful as a tool for managing or for referring identified health problems.Study Part 2: Charts from a total of 1,378 well-baby visits on 176 children were audited. Well-baby care provided by the 20 FP/GPs who used the RBR compared to that by the 18 non-users was statistically more likely to include documentation of type of feeding (p = 0.023), discussion of safety issues (p < 0.001), assessment of development (p = 0.001), and overall comprehensiveness (p < 0.001). Well-baby care provided by the RBR users compared to that by the non-users was not more likely to include documentation of measurement of growth (p = 0.097), or physical examination (p = 0.828).ConclusionThe RBR was widely used by FP/GPs in these settings. RBR users found it helpful for many purposes, and had a consistently high rate of documentation of many aspects of well-baby care. The Rourke Baby Record has become a de facto gold standard clinical practice tool in knowledge translation for pediatric preventive medicine and health surveillance for primary care pediatric providers.

Building Practice Evidence for Parent Mentoring Home Visiting in Early Childhood

Objective: A multidisciplinary preventive parent mentoring intervention was applied through home visiting with high-risk families receiving well-baby health care. Two implementations were examined for effectiveness. Method: The first implementation employed a quasiexperimental nonequivalent group design, whereas the second used a randomized experiment. A multivariate repeated-measures design compared intervention and control families from both implementations on parenting outcomes. Logistic regressions examined children’s outcomes. Results: Compared to controls, intervention families significantly improved their family resources, parenting knowledge, practices, and maternal resilience. Intervention status significantly predicted children’s immunization and early language. Conclusions: Parent mentoring anchored in multidisciplinary approach with empirically informed practices may be a desirable intervention addressing the multifaceted developmental needs of very young children. Limitations and implications for practice are addressed.

The Association of Family Continuity with Infant Health Service Use

Continuity of care is a fundamental component of family medicine that has been shown to improve health care quality. Family continuity, when different family members are seen by the same clinician or practice, has not been well studied. We performed a retrospective cohort study of Medicaid enrollees in Oregon using administrative data. Infants were determined to have family continuity if they received well-baby care at the same clinic as that in which their mothers received prenatal care. Of the 1591 infants identified for participation in this study, 749 (47.1%) had family continuity. Infants had a mean of 4.55 well-child visits, 1.23 emergency department visits, and 0.17 hospitalizations in the first 13 months of life. Multivariate analyses found that infants with family continuity had increased numbers of well-child visits (relative risk, 1.05; P = .041), increased numbers of emergency department visits (relative risk, 1.36; P < .0001), and no difference in the number of hospitalizations (relative risk, 0.85; P = .282) when compared with infants without family continuity. Family continuity, when measured at the clinic level, is associated with a variable effect on infant health service use. This finding suggests that clinic-level continuity is not sufficient for achieving all the benefits of continuity.

Making Pay-For-Performance Work In Medicaid

Findings from a Medicaid pay-for-performance (P4P) demonstration suggest that "money talks" only sometimes, when supportive program elements give it voice. In this paper we examine five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, we identify key program features--including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them--taking into account the starting point. The findings also highlight barriers to improvement that future Medicaid P4P efforts should consider.

Psychosocial Predictors of Being an Underweight Infant Differ by Racial Group: A Prospective Study of Louisiana WIC Program Participants

In order to prospectively identify psychosocial predictors of infants being underweight, we followed 3,302 low-income infants. These infants received well-baby care in health departments and were enrolled in the Women, Infants, and Children (WIC) Supplemental Food Program from the newborn period to 12 months of age. We linked risk factor data collected from newborn medical history records to anthropometric data from a WIC database. The unadjusted relative risk of being underweight at 12 months of age, defined as weight for recumbent length below the 5th percentile, according to current Centers for Disease Control and Prevention growth charts, for each group was calculated for the study population and for black and white racial groups. Using logistic regression, we calculated odds ratios measuring the effect of the newborn risk factors on underweight status at 12 months of age. There were no psychosocial risk factors that were significantly associated with being underweight simultaneously in both racial groups. Among black infants, those whose mothers had an eighth grade education or lower were at greater risk of being underweight at 12 months of age (OR=3.7, CI=1.5-4.8), as were those whose mothers were married (OR=2.7, CI=1.5-4.8). Among white infants, those whose mothers initiated prenatal care in the third trimester were significantly more likely to have underweight infants at 12 months of age (OR=4.5, CI=1.6-12.4). Predictors of being underweight at 12 months of age in a low-income population differ by racial group. Further research of public health interventions targeting families of infants with the significant psychosocial risk factors is needed.

The effect of Taiwan's National Health Insurance on infants’ preventive care use and inpatient care use

Objective To test whether utilization of infant preventive care services has reduced utilization of inpatient care and to determine whether implementation of Taiwan's National Health Insurance (NHI) has brought about any differences in the utilization of infant health care services. Data sources Data were taken from the 1989 and 1996 National Maternal and Infant Health Surveys (NMIHSs). In total, 1662 and 3623 effective samples were used in the study from the 2 years. Study design We constructed a simultaneous recursive model to obtain efficient estimates by treating preventive care (neonatal care and well-baby care) and inpatient care (hospitalization admissions) as dependent variables. Principal findings Utilization of neonatal care had strongly negative significant coefficients for the likelihood of being admitted to the hospital. The impact of the NHI was found to be significant. Conclusions The hypothesis that the NHI interferes with the effectiveness of preventive care at reducing inpatient care use was not reinforced. Since support from the NHI depends on a balance of push and pull between access to inpatient care and the benefits of preventive care, it can further improve infant health by promoting the benefits of preventive care while making both types of care more accessible.

Age of menarche, parity and postpartum weight retention in a racially diverse cohort

Early age at menarche has previously been linked to maternal weight retention following pregnancy. The relationship between age at menarche, parity, and postpartum weight retention was examined in 1255 Black, White, Asian and Hispanic adult women whose infants received well-baby care at the U.S. Naval Medical Center, San Diego, CA. Average follow-up was more than 330 days after birth. Mean age at menarche (years) ranged from 12.3 in Hispanics to 12.8 in Asians; mean postpartum retention (postpartum minus prepregnancy weight, kg) ranged from 3.1 in Asians to 3.9 in Hispanics. Models stratified by race suggested that each additional year of age at menarche was significantly associated with a 0.9 kg and 0.7 kg decrease in retention among primiparous White and multiparous Black women, respectively, after adjusting for gestational gain, height and other covariables. Age of menarche was not significantly related to retention for the other parity and race groups. This study adds to evidence that postpartum weight retention and age of menarche are inversely related, but only in subgroups by race and parity. Supported by the U.S. Department of Defense DAMD 17-96-2-6014

Infant hearing screening at immunization clinics in South Africa

Benefits of early identification and subsequent intervention for hearing loss are not accessible to infants in developing countries like South Africa. There are no systematic screening programs and traditional platforms for newborn hearing screening, such as well-baby and intensive care nurseries, do not provide sufficient coverage due to the high incidence of births at home or in primary healthcare facilities. Primary healthcare structures, in the form of immunization clinics, have been proposed as an alternative screening platform. The current study, therefore, investigates a hearing screening program implemented at two immunization clinics in a representative South African community. The two clinics in the current study were selected by a convenience sampling method in a community representative of large sections of the population. The hearing screening program was conducted over a 5-month period, and enrolled 510 infants (0-12 months of age). The screening protocol included Distortion Product Oto-Acoustic Emissions (DPOAE) and a high frequency probe tone (1000 Hz) tympanogram. Referral was based on one or both ears referring the DPOAE screen. Follow-up screening and diagnostic evaluations were scheduled for referred subjects. Coverage with DPOAE amounted to 95% of the sample ears (93% of sample subjects) compared to tympanogram coverage amounting to 94% (93% of sample subjects). OAE pass rates were 93% for the sample ears with neonatal ears indicating a higher pass rate of 95% compared to 92% for infant ears (5-52 weeks of age). Eighty-seven percent of the sample ears indicated peaked tympanograms indicative of normal middle-ear functioning and neonatal ears presented with an increased incidence of peaked tympanograms (92%). A highly significant association between the DPOAE and high frequency tympanometric result was found. Follow-up screening appointments were scheduled for 68 subjects (14% of screened sample). Only 40% returned for the second follow-up and 44% for the third follow-up. Immunization clinics indicate promise as infant hearing screening platforms, but identification of only bilateral hearing losses may be warranted initially to keep referral rates acceptably low. In addition to this efficient tracking systems are necessary to ensure acceptably high follow-up return rates are reached over time.

Salvadoran fathers' attendance at prenatal care, delivery, and postpartum care

To provide a baseline perspective on the prevalence of Salvadoran men's attendance at prenatal care, delivery, and postpartum well-baby care and on sociodemographic factors associated with their attendance, with the goal of informing efforts to help men play more positive roles in maternal-child health. The data came from the 2003 Salvadoran National Male Health Survey. The data focused on fathers (n = 418) and their most recent live-born child in the preceding five years. Factors associated with the fathers' participation in prenatal care visits, attendance at delivery, and participation in postnatal well-baby visits were explored using logistic and multinomial regression models. Ninety percent of the recent Salvadoran fathers who were surveyed participated in a prenatal care visit, attended the delivery, or participated in a postpartum well-baby care visit; 34% participated in all three of the activities. Attendance at delivery was most common, reported by 81% of fathers; the most common reason that subjects cited for not attending was that they had had to work. A large majority of the Salvadoran fathers participated in at least one prenatal care visit, delivery, or a postpartum well-baby care visit. While attendance alone does not necessarily indicate that men are supporting their partners, the results suggest that norms are in place for men to play positive roles in maternal-child health matters. Furthermore, the participation of fathers in these maternal and child health care activities may provide new opportunities to educate and further support men in both their own health and their family's health.

The Taiwan National Health Insurance Program and Full Infant Immunization Coverage

We compared hospital-born infants and well-baby care use associated with complete immunizations in Taiwan before and after institution of National Health Insurance (NHI). We used logistic regression to analyze data from 1989 and 1996 National Maternal and Infant Health Surveys of 1398 and 3185 1-year-old infants, respectively. Infants born in hospitals were found to receive fewer immunizations than those born elsewhere before NHI but significantly more after NHI. Use of well-baby care correlates strongly and positively with the probability that a child will receive a full course of immunization after NHI. The NHI policy of including hospitals as immunization providers facilitates access to immunization services for children born in those facilities. Through NHI provision of free well-baby care, health planners have stimulated the demand for immunization.

Utilization of well-baby care visits provided by Taiwan's National Health Insurance Program

In April of 1995, Taiwan's National Health Insurance Program started providing each eligible child a total of six well-baby care visits. The first four are for infancy, the fifth is for the second and the third years of life, and the sixth is for the fourth year. These services are in addition to neonatal screening and a series of primary immunizations that have been publicly financed and utilized conventionally for years. The purposes of this study were to investigate the utilization level of these well-baby care visits, and explore relevant factors. The results reveal that 36% of eligible children did not use any of the first four visits, 58% did not utilize the fifth, and 82% did not use the sixth in the late 1990s. It appears that the take-up of these services is much less than satisfactory. Maternal awareness of and attitudes toward the services appeared to be the most important factors influencing utilization. These two factors not only were most influential, but also significantly contributed to disparities in utilization among different regions and types of residential districts. As a result, they should be the focus of interventions for advancing well-baby care. While these two factors are at the individual level, they are not independent from the health care system because the health care system has impacts on individual factors. Since physicians can serve as a good vehicle for teaching parents about relevant information and correct attitudes, and most physicians in Taiwan complained about the payment scheme, offering stronger incentives for physicians to promote such services might be helpful for achieving a high utilization level of well-baby care.

Utilization of well-baby care visits provided by Taiwan's National Health Insurance Program

Utilization of well-baby care visits provided by Taiwan's National Health Insurance Program

Physical Abuse of Women Before, During, and After Pregnancy

Main Outcome Measures Prevalence of physical abuse during the 12 months be- fore pregnancy, during pregnancy, and after infant delivery; injuries and medical in- terventions resulting from postpartum abuse; and patterns of abuse over time in re- lation to sociodemographic characteristics and use of well-baby care. Results The prevalence of abuse before pregnancy was 6.9% (95% confidence in- terval (CI), 5.6%-8.2%) compared with 6.1% (95% CI, 4.8%-7.4%) during preg- nancy and 3.2% (95% CI, 2.3%-4.1%) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medi- cal treatment for their injuries. Virtually all abused and nonabused women used well- baby care; private physicians were the most common source of care. The mean num- ber of well-baby care visits did not differ significantly by maternal patterns of abuse. Conclusion Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.

Adolescent mothers' beliefs about parenting and injury prevention: Results of a focus group

Introduction: A nonfatal injury occurs every 2 seconds in the United States, and approximately 30,000 children die each year from injury-related causes. The U.S. Department of Health identified the reduction of unintentional injuries as a major health goal. The current study reports on a focus group discussion conducted with adolescent mothers to examine their beliefs and practices regarding injury prevention. Method: Seventeen first-time adolescent mothers participated in the focus group. Participants responded to questions about important aspects of mothering, causes of injury, and strategies to prevent injuries. Responses were categorized. Results: No mother spontaneously identified injury prevention as an important part of mothering. More than half of all participants believed that injuries are unpreventable. Further, mothers identified a limited number of strategies to prevent injury. None of the mothers reported having discussed injury prevention with their child's pediatrician. Discussion: Implications for care are discussed, including the need to address issues of injury prevention during well-baby care, the potential benefits of home visits, and specific challenges in implementing The Injury Prevention Program with young mothers. J Pediatr Health Care. (2001). 15, 194-199.

Well-Baby Care Visits Create Opportunity to Screen New Mothers for Abuse during Postpartum Period

Well-Baby Care Visits Create Opportunity to Screen New Mothers for Abuse during Postpartum Period

Screening Mothers for Intimate Partner Abuse at Well-Baby Care Visits

Context Clinicians who care for new mothers and infants need information concerning postpartum physical abuse of women as a foundation on which to develop appropriate clinical screening and intervention procedures. However, no previous population-based studies have been conducted of postpartum physical abuse. Objectives To examine patterns of physical abuse before, during, and after pregnancy in a representative statewide sample of North Carolina women. Design, Setting, and Participants Survey of participants in the North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS). Of the 3542 women invited to participate in NC PRAMS between July 1, 1997, and December 31, 1998, 75% (n=2648) responded. Main Outcome Measures Prevalence of physical abuse during the 12 months before pregnancy, during pregnancy, and after infant delivery; injuries and medical interventions resulting from postpartum abuse; and patterns of abuse over time in relation to sociodemographic characteristics and use of well-baby care. Results The prevalence of abuse before pregnancy was 6.9% (95% confidence interval [Cl], 5.6%-8.2%) compared with 6.1% (95% Cl, 4.8%-7.4%) during pregnancy and 3.2% (95% Cl, 2.3%-4.1 %) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medical treatment for their injuries. Virtually all abused and nonabused women used well-baby care; private physicians were the most common source of care. The mean number of well-baby care visits did not differ significantly by maternal patterns of abuse. Conclusion Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.

Physical abuse of women before, during, and after pregnancy.

Clinicians who care for new mothers and infants need information concerning postpartum physical abuse of women as a foundation on which to develop appropriate clinical screening and intervention procedures. However, no previous population-based studies have been conducted of postpartum physical abuse. To examine patterns of physical abuse before, during, and after pregnancy in a representative statewide sample of North Carolina women. Survey of participants in the North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS). Of the 3542 women invited to participate in NC PRAMS between July 1, 1997, and December 31, 1998, 75% (n = 2648) responded. Prevalence of physical abuse during the 12 months before pregnancy, during pregnancy, and after infant delivery; injuries and medical interventions resulting from postpartum abuse; and patterns of abuse over time in relation to sociodemographic characteristics and use of well-baby care. The prevalence of abuse before pregnancy was 6.9% (95% confidence interval [CI], 5.6%-8.2%) compared with 6.1% (95% CI, 4.8%-7.4%) during pregnancy and 3.2% (95% CI, 2.3%-4.1%) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medical treatment for their injuries. Virtually all abused and nonabused women used well-baby care; private physicians were the most common source of care. The mean number of well-baby care visits did not differ significantly by maternal patterns of abuse. Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.