n
Zoe Confidential
Page 1
4/27/2016
Evidence
of Cost
Savings
and
Improved
Outcomes
Maternal and
Pediatric Health
Management
April, 2002
Copyright: Zoe Consulting, Inc.
D:\681446458.doc
Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 2
Low birthweight is associated with long term disabilities like cerebral palsy, autism, mental
retardation, vision and hearing impairments and other developmental disabilities. Despite the
number of pregnancies resulting in low birth weight babies; expenditures for care of these infants
total more than half of the costs incurred for all newborns. In 1988 the average costs incurred for a
normal healthy delivery averaged $1900 whereas hospital costs in 1995 for LBW infants averaged
$6,200. Lewitt, EM; Baker, LS; Hope C; et al. The Direct Costs of Low Birth Weight. Future Child
5(1):35-56, 1995. The good news is there is this is an area where achieving optimal financial
and health status outcomes is possible. Research has shown what works and what does not.
One of the challenges is to be sure existing programs have kept up with the research and have
changed accordingly. This document is a compilation of some of the research and studies that
make the case that maternity management programs with planning and inclusion of essential
elements, can achieve improved outcomes and cost savings.
The past decade has revealed and taught us both disappointing strategies and promising
developments for cost effective interventions for achieving optimal outcomes and costs savings.
Some related to causes others related to new interventions and research supporting existing
interventions. Some promising interventions include but limited too: preconception and interconception elements (folic acid, pregnancy spacing), low pre-pregnancy weight, tobacco
use/smoking, alcohol and illegal substance abuse, hydration, nutrition, diabetes management; both
type 1 and gestational, hypertension management, co-morbidity, infections, depression, anxiety,
domestic violence, improving coping skills for dealing with stressors, appropriate weight gain
during pregnancy, and simple things that make a major difference like patients knowing how to
detect preterm labor and what to do if suspected; and use of behavioral change techniques to
facilitate desired changes and adherence to prescribed treatments and to the physician’s plan of
care, as well as patient managers being trained in and using effective patient communication skills
during interview and coaching, and so forth. There are new findings that warrant observing
research related to infections and biochemical markers. Additionally, breastfeeding, prevention and
treatment of disabilities in children, and so forth are other areas that are cost effective.
Live Infant birth is the top reason for hospital admission in the U.S. reported to exceed $3.8 million
in 1999. Two of the top five most expensive hospital diagnoses are Infant respiratory distress
syndrome (ranked 2nd) averaging $56,000 per hospital stay, and Low Birth Weight (ranked 3rd)
averaging $50,300 per hospital stay. These costs are reduced with proper and timely intervention
and introduction of treatment to help with lung maturity through pregnancy management programs.
U.S. Agency for Health Care Policy & Research, Publs No. 99-0034 and 99-0046, Rockville MD.
Zoe Consulting, Inc. is a valued source in helping to assess your programs strengths and
weaknesses in order to implement essential elements for what will achieve optimal financial,
maternal and infant health outcomes. Zoe is represents an award winning approach to cost
effectively achieving desired results and return on investment.
Please call if you have questions or need more information. Enjoy!!!
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 3
Preconception/Prenatal:
 Daily supplementation with 4 mg of folic acid starting before conception and continuing
through the first three months of pregnancy prevented 71% of the recurrences of neural tube
defects – a 3.5 fold protective effect. (Pending further research CDC recommends folic acid
supplementation (4 mg/day) for women who previously have had an infant with spina bifida,
anencephaly, or encephalocele. Note: physicians should be aware that folic acid at 4 mg/day
might complicate the diagnosis of vitamin B12 deficiency).
[1] Lynberg MC, Khoury MJ. Contribution of birth defects to infant mortality among
racial/ethnic minority groups, United States, 1983. In: CDC surveillance summaries, July
1990. MMWR 1990; 39 (SS-3): 1-12.
[2] Little J, Elwood JM. Epidemiology of neural tube defects. In: Kiley M, Ed.
Reproductive and perinatal epidemiology. Baca Raton, Florida: CRC Press, 1991: 251336.
[3] MRC Vitamins Study Research Group. Prevention of neural tube defects: results of the
Medical Research Council Vitamin study. Lancet 1991; 338: 131-7.
[4] International Clearance for Birth Defects Monitoring Systems. Congenital malformations
worldwide: a report from the International Clearinghouse for Birth Defects Monitoring
Systems. Amsterdam: Elsevier, 1991: 41-51.
[5] CDC. Economic burden of spina bifida – United States, 1980-1990. MMWR 1989; 38264-7.
[6] Anonymous. Folic acid and neural tube defects (Editorial). Lancet 1991; 338:153-4.
[7] Khoury MJ, Erickson JD, James LM. Etiologic heterogeneity of neural tube defects:
Clues from epidemiology. Am J Epidemiol 1982; 115-538-48.
[8] Khoury MJ, Erickson JD, James LM. Etiologic heterogeneity of neural tube defects II.
Clues from family studies. Am J Hum Genet 1982; 34:980-7.
[9] Smithells RW, Sheppard S, Schorah CJ, et al. Apparent prevention of neural tube defects
by periconceptional vitamin supplementation. Arch Dis Child 1981; 56:911-8.
[10] Bower C, Stanley FJ. Dietary folate as a risk factor for neural tube defects: evidence
from a case-control study in Western Australia. Med J Aust 1989; 150: 613-9.
[11] Milunsky A, Jick H, Jick SS, et al. Multivitamin/folic acid supplementation in early
pregnancy reduces the prevalence of neural tube defects. JAMA 1989;262:2847-52.
[12] Multinare J, Cordero JF, Erickson JD, Berry RJ. Periconceptional use of multivitamins
and the occurrence of neural tube defects. JAMA 1988; 260:3141-5.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 4
[13] National Research Council. Recommended daily allowances: report of the Committee
on Dietary Allowances Food and Nutrition Board, Division of Biological Sciences,
Assembly of Life Sciences, 10th ed. Washington, DC: National Academy Press, 1989.
 Cost-Benefit Analysis of Preconception Care for Women with Established Diabetes Mellitus.
Elixhauser, A.; Wechsler, J.M.; Kitzmiller, J.L.; Marks, J.S.; Bennert Jr., H.W.; Coustan, D.R.;
Gabbe, S.G.; Herman, W.H.; Kaufmann, R.C.; Ogata, E.S.; Sepe, S.J. Diabetes Care.
16(8):1146-1157. August 1993.
OBJECTIVE: To determine whether the costs of pre-conception care in women with
diabetes are balanced by the savings that result from avoiding complications.
CATEGORY: Diabetes in pregnancy.
Type of Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION: Intensive preconception care for women with diabetes followed by
prenatal care is cost saving when compared with prenatal care only.
 Cost-Benefit Analysis of Preconception Care for Women with Established Diabetes Mellitus.
Final Report. Elixhauser, A.; Weschler, J.M. Battelle Medical Technology and Policy Research
Center, Washington, D.C., 1990.
OBJECTIVE: To analyze and compare costs and benefits of preconception care plus
prenatal care versus prenatal care only in preventing adverse fetal and maternal outcomes in
women with pre-existing diabetes mellitus.
CATEGORY: Diabetes in pregnancy.
Type of Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION: The program of preconception care plus prenatal care resulted in net
savings of $1.7 million; the greatest savings were associated with reduction of adverse
outcomes in mothers and infants.
 Financial Implications of Implementing Standards of Care for Diabetes and Pregnancy.
Elixhauser, A.; Weschler, J.; Kitzmiller, J.; Bennert, H.; Coustan, D.; Gabbe, S.; Herman, W.;
Kauffmann, R.; Ogata, E.; Marks, J.; et al. Diabetes Care. 15 (Supplement 1): S22-S28. March
1992.
OBJECTIVE: To examine the financial implications of implementing standards of care for
pregnancy among women with diabetes.
CATEGORY: Diabetes in pregnancy.
Type of Study: Patient management.
Methodology: Review of studies.
Perspective: Health care system.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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CONCLUSION: Implementing standards of care for pregnancy among women with
diabetes will represent a greater use of health care resources for outpatient preconception
and prenatal care but can lead to avoided costs for maternal and fetal complications of
pregnancy.
 Prevention: The Cost-Effectiveness of the California Diabetes and Pregnancy Program.
Scheffler, R.M.; Feuchtbaum, L.B.; Phibbs, C.S. American Journal of Public Health. 82(2):
168-175. February 1992.
OBJECTIVE: To determine the cost-effectiveness of a California program aimed at
improving pregnancy outcomes through intensive diabetes management.
CATEGORY: Tertiary intervention.
Type of Study: Retrospective.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION: The program significantly reduced hospital charges and length of stay; it
returned over $5 for every $1 spent.
 Women with Diabetes During Pregnancy: Sociodemographics, Outcomes, and Costs of Care.
York, R.; Brown, L.P. Public Health Nursing. 12(5): 290-293. October 1995.
OBJECTIVE: To provide sociodemographic, outcome, and cost data for pregnancy
through the postpartum period for predominantly low-income women with diabetes who
were hospitalized during pregnancy for glucose control.
CATEGORY: Diabetes in pregnancy.
Type of Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION: Women in the study were three times as likely as those in the general
Pennsylvania population to deliver low-birthweight infants; mean hospital charges for these
infants were $39,787. Savings through appropriated patient management programs are
great.
 Reducing Preterm and Low Birthweight Births, Mary Lou More PhD, RNC, FACCE, FAAN
and Margaret C. Freda EdD, RN, CHES, FAAN; MCN, vol.23, No 4, 206-208, July/August
1998. Most primary and secondary prevention strategies are clearly in the domain of nursing
and health educating. If we focus on shifting to supporting and educating pregnant women and
their families and to addressing the factors that may lead to preterm and LBW births; pregnancy
outcomes in the United States could look much different in the future than they do today.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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 Long awaited data related to the alpha-hydroxyprogesterone caproate (17P) study was released
in NEJM today. Preterm births were reduced by about 50% in women who had experienced a
prior preterm birth. Results may not be in PubMed yet but abstract is on NEJM web site
www.nejm.org (7/2003)
 CIGNA Healthcare of Southern California’s Healthy Babies program reports
 25% decrease in preterm delivery
 33% decrease in very low birth weight infants (VLBW)
 2% reduction in low birth weight infants (LBW)
 Reduction in NICU admissions and LOS
 42% decrease in low (<7) APGAR scores
 An increase from 51% to 77% of women securing prenatal care in the first trimester
(HEDIS) and 76% to 98% who receive any prenatal care
(Healthcare Demand and Disease Management, April 1987; page 151)
 A cost-benefit analysis of smoking cessation programs during the first trimester of pregnancy
for the prevention of low birthweight found; programs with 18% quit rates were cost effective if
the program cost less than $80, or for 25-30% quit rates the program cost needed to be less than
$135/pregnant participant. (William J. Hueston, MD, et al., The Journal of Family Practice,
October 1994).
 For each dollar spent on smoking cessation programs for pregnant women, $7 to $17 is saved in
health care costs (Windsor, RA, et al, AJPH, 1993).
 Matria Healthcare Inc. reported $45million in health care cost savings based on 121,000 births
during a four year period from 1997 through 2000. The 2002 Disease Management Directory
Guidebook, National Health Information Inc., Atlanta GA; p 458. www.nhionline.net
 In 1991, Trigon BlueCross BlueShield (Richmond, VA) reported through a paired actuarial
analysis the following:
- Saved over $330,000 in claims amounts with Low Birth Weight (LBW)
and Very Low Birth Weight (VLBW) rates
- Shorter LOS
All maternity
All pre-term delivery
Study
4.11
18.55
- 30% net savings
- 3.7% savings in all maternity cases
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Control
4.69
23.07
Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 7
The program continues to report solid return on investment and favorable LBW and VLBW
rates compared various State and National norms. In 1998 a study was conducted on a 214,000
PPO organization utilizing claims from 1995 through 1997. The maternity management
program was provided in 1994 but discontinued in 1995; thus providing a controlled setting to
study since the benefits structure remained the same. Conclusions:
- Average cost per case was 8.7% higher in 1996 and 9% higher in 1997. Compared to 1995.
- Infant prematurity cases as a percent of all maternity increased from 0.9% in 1995 to 2.3% in
1996 and 1997; increasing expense related to prematurity by more than 110% from 1995 to
1997.
- Longer hospital stays due to legislative mandate contributed to cost increases.
 In 1996 a 21,000 member Trigon Medicaid HMO reported over $300,000 in savings and no
premature births during a 12-month study period.
 The Baby Benefits program provided by Health Management Corporation of Richmond,
Virginia, has several studies documenting the program’s effectiveness. Baby Benefits was the
first program of its kind in the United States and received the peer reviewed and judged; 1995
C. Everett Koop award for excellence in health management
Below is a 1995 programmatic evaluation with a denominator of 585,000 contracts.
Delivery outcomes by low birthweights (defined as <2500 grams)
National Average
State of Virginia Average
Baby Benefits Participants Average
Delivery outcomes by Very Low Birthweights
National Average
State of Virginia Average
Baby Benefits Participants average
Delivery outcomes by NICU days/1000
Baby Benefits Participants
National Average
Return on Investment
$1.00 invested
Zoe Consulting, Inc.
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<2500g
8.4%
7.4%
5.2%
(1500g)
1.3%
1.5%
.8%
184 days/1000
248 days/1000
$3.63 savings
Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 8
In 1990, a retrospective actuarial analysis conducted by Trigon BlueCross BlueShield,
Richmond, Virginia, showed a 20% savings on premature births claims, fewer premature births,
lower average cost per premature birth, a 4% savings on overall obstetric claims, and a net 30%
savings to the health plan. Sara Lee Corporation also reported success with the program, with
8% savings in obstetric claims related to premature births. (Maternity Risk Management: from
Preconception to After Delivery, Foust, Robin F., Journal of Care Management, Volume 3, No
1; Feb 1997: 22-46).
 Kogan reported a 25% reduction in the LBW rate for women receiving information. Women
who reported not receiving all recommended health behavior advice during pregnancy had a
significantly higher risk of delivering a LBW infant. More than 2/3s of women did not recall
receiving advice on all the recommended topics of health behavior during pregnancy; while 1/3
received no information on tobacco, alcohol or drug use; or on breastfeeding.
(Kogan MD, Alexander R, Kotelchuck, et al. Relation of the content of prenatal care to risk of
low birthweight. JAMA. 1994; 271 (17): 1340-1345).
 A survey of 9,394 women collecting data on the relation of the content of prenatal care to the
rest of low birth weight concluded that women who reported receiving sufficient health
behavior advice as part of their prenatal care are at lower risk of delivering a LBW infant.
(JAMA. 1994; 271:1340-1345)
 A randomized controlled trial studying the effect on pregnancy outcomes for childhood injuries,
and repeated child bearing, with prenatal and infancy home visitation by nurses, concluded that
home visitation by nurses can reduce pregnancy induced hypertension (PIH), childhood injuries
and subsequent pregnancies among low income women with no previous live births (JAMA.
1997; 278:644-652)
 The authors of a British study report a correlation between self-reported anxieties and reduced
uterine blood flow. This study supports the wisdom that attention to the psychological well
being of the mother is important to a healthy outcome for the pregnancy. (Texiera JMA et al.
Association Between Maternal Anxiety in Pregnancy and Increased Uterine Artery Resistance
Index: Cohort Based Study. BMJ 1999 Jan 16; 318:153-7.)
 A Utah study of over 173,000 live births, revealed an increased risk for adverse perinatal
outcomes for infants conceived after very short, or very long-term birth intervals, less than 18
months or longer than 10 years, following the previous birth. Infants conceived 18 to 23
months after a previous live birth were at lowest risk for low birth weight and preterm birth.
Clinicians and programs should address the contraceptive needs of postpartum women to reduce
these risks. ( Zhu B-P et al. Effect of the Interval Between Pregnancies on Perinatal Outcomes.
N Engl J Med 1999 Feb 25; 340: 589-94. Klebanoff MA The Interval Between Pregnancies and
the Outcome of Subsequent Births. N Engl J Med 1999 Feb 25; 340:643-4.)

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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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 The National Institutes of Mental Health estimate 7.9% of women in the US experience
depression during their lifetime, and about 70-80% experience some type of postpartum
depression usually beginning about 2-3 days after birth; with about 10% developing sever
postpartum depression
 Depression can be a significant problem both during and after pregnancy and intervention can
improve outcomes and save health care costs. Evans J, et al. Cohort study of depressed moood
during pregnancy and after childbirth. BMJ 2001, Aug 4; 323:257-260.
 A simple list of event predictors can index to identify candidates for preconception and prenatal
cardiac intervention and for referrals to regional centers for more intensive pregnancy
management. Siu SC, et al on behalf of the Cardiac Disease Pregnancy Investigators.
Prospective multi-center study of pregnancy outcomes in women with heart disease.
Circulation; 2001 Jul 31; 104:515-521.
 AHCP and MEDTEP study at the University of California; San Francisco found women who
did not receive support visits (1 each trimester) had 2 times the risk of a poor outcome
compared to those who did. (1997)
 The Packard Foundation (1995) found low birthweight rates hinged on integrating Medicaid and
social services during prenatal care.
 Resource mothers (RM) from the Norfolk, Virginia Healthy Start Incentive making regular
home visits with medically assisted pregnant women report (1997) lower birth weight rates:
0 .2 5
2 2 .3 0 %
0 .2
0 .1 5
1 0 .2 0 %
1 1 .1 0 %
0 .1
0 .0 5
0
B irthweight
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RM Data
Virginia Data
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C ontrol
Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
Page 10
 HealthKeepers Plus: Low Birthweight Percentages for Baby Benefits
February 1, 1996 – September 30, 1996
LBW%
Richmond HealthKeepers Plus
With Ante-partum Home Health Visits
Without Ante-partum Home Health Visits
Plan Total
Peninsula HealthKeepers Plus
5.0%
16.7%
11.4%
15.6%
# of LBW
Infants
1
4
5
15
# of
Deliveries
20
24
44
96
Low Birthweight Percentages
1 6 .7 0 %
1 8 .0 0 %
1 5 .6 0 %
1 6 .0 0 %
1 4 .0 0 %
1 1 .4 0 %
P ercentage
1 2 .0 0 %
1 0 .0 0 %
8 .0 0 %
5 .0 0 %
6 .0 0 %
4 .0 0 %
2 .0 0 %
0 .0 0 %
R i c hm o nd H e al thKe e pe r s P l us
W i th Ante -P ar tum Vi s i ts
P e ni ns ul a H e al thKe e pe r s P l us
W /O Ante -P ar tum Vi s i ts
P l an To tal
Source: Health Management Corporation, Richmond, VA
(Case Management Advisor; May, 1997: page 90)
Interconception care: Women with inter-pregnancy intervals from 18-59 months had the
lowest rate of premature and moderately preterm infants; Inter-pregnancy Interval and the
Risk of Premature Infants, Fuentes-Afflick, MD, et al, Obstet Gynecol, Vol. 95, No. 3,
March 2000
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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Short or Long Conception Intervals: Marker for High Risk Pregnancy: Ahu B-p et al. Effect
between pregnancies on perinatal outcomes, N Engl J Med, 1999 Feb 25;340:580-94, and
Klebanoff MA, The Interval between pregnancies and the outcome of subsequent births. N
Engl J Med 1999 Feb 25; 340:643-4. Investigators analyzed 173,000 births in Utah
controlling for age, race, marital status, education, alcohol and tobacco use, and adequate
prenatal care. Infants conceived 18-23 months after a previous live birth were at lowest risk
for low birth weight, preterm birth, and small size for gestational age. Likewise pregnancies
started less than 6 months after birth had a 40% increased risk for adverse perinatal
outcome; and when conception took place 10 years or more after live birth the risk almost
doubled.
 Trigon Blue Cross’s BabyBenefits program following a two year study showed that the
program yielded better outcome for women and their babies, thus reducing maternity care
costs and providing impressive value for participating patients and companies.
The study covered the period from July 1, 1997 through June 30, 1999, and compared
claims data for a group of 1,237 fully-insured women participating in BabyBenefits to a
matched population of 1,237 woken from self-insured groups not eligible for the program.
Group members were matched according to several characteristics, including age, region in
the State of Virginia where the woman delivered, and clinical factors such as chronic and
gestational diabetes, chronic and pregnancy-induced hypertension, and multiple gestations.
The Study indicated that the study group had lower average maternal related expenses
compared to the matched population of those not eligible for the program; the control group:
 A 6.9 % lower overall adjusted average maternal cost per case for the study group
 An 8.1 % lower overall adjusted average maternal cost per day fro the study group.
Other findings included:
 NICU stays were an average 15.4% shorter for the study group
 The Study group required 10% fewer NICU dayus/1000 births than the control
group
 The adjusted NICU average cost per case was 40% lower for the study group due to
both shorter stays and less intensive treatments
 Average infant prematurity related costs per case were 32% lower for the study
group.
 For the study group, the average total maternal prematurity cost per case was 11.5%
lower than the control group.
 The program since 1989 continues to prove its value to achieving optimal birth and financial
outcomes; documenting a $3.80 ROI for every dollar invested. (Women’ Health – NHI
Publications)
 Prenatal care (PNC) is an available predictor for birth weight, preterm birth, and newborn
health. 25 Prenatal care can improve birth outcomes and prevent medical complications and
their costs associated with low birth weight infants.31Pregnant teens 15-19 years of age are
less likely to get early PNC (66.3% in 1995) compared with all pregnant women (81.8% in
1996).10,11
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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More than one-quarter of births in the United States are financed by Medicaid. 30 Expenses
related to childbirth have become the single largest component of employers private plan
health care costs (10 to 40 percent), so tracking this major measure offers value. 17 Family
planning reduces unintended pregnancies and short interpregnancy intervals. 19 If a
pregnancy is planned, a woman is more likely to seek early and adequate PNC. 19 PNC
helps identify and treat pregnant women at risk of preterm and low birth weight births.
Costs
For every dollar spent on prenatal care, an estimated $1.70 to $3.38 is saved based on the
pregnant woman's risk factors. 18 Comprehensive prenatal care services costs range from
$380 to $1,042 per pregnancy while cost savings after delivery ranged from $347 to $13,616
per pregnancy. 18 Savings depends on if prenatal care effectively prevents low birth weight
infants. 18
Mothers testing positive for cocaine were more likely to deliver prematurely (37% versus
2%) and have a low birth weight (2613 vs. 3340 grams) or growth-retarded infants (12% vs.
0%). Infants exposed to cocaine more often require neonatal intensive care (30% vs. 3%)
and stay in the hospital on average a week longer with higher costs ($13,222) than infants
not exposed during pregnancy ($1,297). 26,32 Treatment for alcohol abuse during pregnancy
might reduce the annual costs of $74.6 million spent to treat infants with fetal alcohol
syndrome (FAS). 26,33
National Trends
A higher percentage of pregnant women are getting early prenatal care during the first
trimester. A smaller percentage of women are getting late prenatal care but the percentage
getting no prenatal care, 5-7%, remains unchanged. 34
Birth rates for women of the healthiest child bearing ages, 20-29 years, have been falling.
Birth rates are rising for women 35 years of age and older.12
Birth rates are rising for unmarried women.13
 Home care from advanced practice nurses key to better health for at-risk
pregnant mothers and their infants - at reduced costs to the healthcare
system. NIH/National Institute of Nursing Research; AUG 14, 2001.
www.eurekaalert.org , Study findings show that a prenatal care intervention in
the home delivered by nurse specialists with master's degrees can reduce infant
mortality, improve maternal and infant health, and lower healthcare costs.
These results from a study conducted at the University of Pennsylvania appear
in the August issue of The American Journal of Managed Care. The study was
funded by the National Institute of Nursing Research, NIH.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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Study findings: Findings show that for those receiving home visits compared
to usual care:
· Infant mortality was lowered (2 versus 9 deaths)
· There were 11 fewer preterm births than controls
· More twin pregnancies were carried to term (77.7% versus 33.3%)
· There were fewer prenatal (41 versus 49) and infant (18 versus 24 re-hospital readmissions
Savings to the healthcare system were significant -- over 750 hospital days and
$2,880,000.
Participants in the study were 173 women with high-risk pregnancies and 194
infants. Most were low-income African American Medicaid recipients. Women
in the intervention group received half of their prenatal care in the home from
advanced practice nurses and half from physicians at the University of
Pennsylvania hospital clinic. During the postpartum period, mothers and
infants received one home visit and eight weekly phone calls from the nurse,
who was also reachable daily by phone.
The control group received standard prenatal and postpartum care for high risk
patients, provided at the hospital clinic. For both groups, health outcomes and
costs were examined during the prenatal period through a year after birth.
According to Dr. Dorothy Brooten, the study's principal investigator, "These
findings demonstrate the importance of an approach that prolongs pregnancies,
which improve the health of mother and child. Concurrently, we can also save
money. This is especially important for patient groups at high risk for infant
mortality and other pregnancy-related problems, such as low income African
Americans."
The prenatal home visits involved education and care for maternal and fetal
health, as well as counseling and referrals. Other advantages related to fewer
hospital clinic visits, which reduced transportation problems, need for childcare, and long waits to be seen. "For some women," added Dr. Brooten,
"coming to the clinic for prenatal care involved 10 hours out of their day door
to door."
Dr. Patricia Grady, Director of the National Institute of Nursing Research, said
"The implications of this intervention for managed care are significant improved quality of care, shortened patient stays in the hospital, and reduced
costs. Furthermore, this study has successfully addressed an important health
disparity involving a vulnerable population that is subject to poor pregnancy
outcomes."
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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The intervention used in this study is a modification of a model of transitional
care provided by nurses with master's degrees, developed by Dr. Brooten and
colleagues, and tested with a variety of patient populations -- with similar
favorable results. These patients included older people, pregnant women with
diabetes, women having hysterectomies, women after unplanned Cesarean
births, and very low birthweight infants.
The National Institute of Nursing Research is a component of the National
Institutes of Health, U.S. Department of Health and Human Services.
Other Medicaid: Maternal and Child Health:
Although the aged, blind, and disabled account for the largest share of program costs, most
Medicaid recipients are poor children and their mothers. About half of all Medicaid recipients are
children and as noted earlier, Medicaid pays for about a third of all births in the United States.
AHCPR research has indicated many ways that Medicaid, and other providers of care to children
and pregnant women, can increase quality and reduce costs. For example:
Diabetes in pregnancy: Preconception care and enhanced prenatal care for women with diabetes
can prevent complications for pregnant women and their babies, thereby increasing quality of care
and saving $1,720 per enrolled woman with diabetes. If the AHCPR-suggested model were
followed for even 20 percent of diabetic pregnancies, the country could save over $8.6 million a
year. Since the Medicaid program would be likely to cover at least a third of these pregnancies, the
costs savings for Medicaid could reach almost $3 million a year (Elixhauser, Weschler, Kitzmiller,
et al., 1993).
Primary care for high-risk indigent infants: A demonstration was designed to reduce mortality
among low birthweight infants after hospital discharge and thereby reduce the need for intensive
care for premature infants in the first few months after discharge. Most of the mothers involved in
the study were teenagers from black and Hispanic Dallas neighborhoods. Jon E. Tyson, Principal
Investigator (Grant No. HS06837; period: l/1/92-6/30/97).
Prenatal care and infant health: New York State began a major expansion of its Medicaid
program in 1990. A current AHCPR-funded study is examining the impact of these changes on
prenatal care use and birthweight distribution among African-American, white, and Hispanic
enrollees between 1988 and 1991. Theodore Joyce, Principal Investigator (Grant No. HS08424;
period: 9/94- 12/95). To help determine whether large-scale statewide programs can succeed in
reducing adverse birth outcomes, AHCPR funded an evaluation of particular components
Washington’s 1989 Medicaid expansion. Laura-Mae Baldwin, Principal Investigator (Grant No.
HS06846; period: 4/l/94-9/30/97).
Middle-ear illness: Otitis media or middle-ear illness is common in young children. AHCPR
recommendations for reducing unnecessary interventions for middle-ear infection in children under
3 could save many children and their families the trauma of surgery, and could also save the
country $170 million in medical and indirect costs, even if only one provider in five adopted the
guidelines. (Lewin, Rubin, and Gold, et al, 1994). Because Medicaid covers a quarter of all
children, about $40 million of this savings could accrue to Medicaid programs. For this reason,
State Medicaid programs such as Oregon’s are planning to use the otitis media guideline as part of
their annual managed care external review.
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Immunizations: An AHCPR-funded study found that a vaccine program for children under 6 could
prevent 3.7 million chickenpox cases, 3,900 hospitalizations, and 52 deaths each year. Net savings
in medical costs and lost work days for Medicaid patients and their families would exceed $150
million a year (in 1990 dollars). If a quarter of these savings accrued to the Medicaid program,
savings could reach over $37 million a year (Lieu, et al., 1994).
A recent AHCPR study developed strategies for improving the dissemination and adoption of all
pediatric vaccine guidelines. Thomas R. Konrad, Principal Investigator (Grant No. HS07286;
period: 7/1/92- 6/30/96).
Preventive and well-child care: Only one-third of poor preschool children and half of those from
more affluent families receive the recommended number of well-child visits, according to a national
health survey conducted by AHCPR (AHCPR, 1994). Increasing use of these services can improve
outcomes and reduce costs. An AHCPR-funded study assessed the impact of periodic feedback and
financial incentives on use of preventive services in a mandatory Medicaid HMO and found no
differences between intervention and control groups. Alan L. Hillman, Principal Investigator (Grant
No. HS07634; period: 4/1/93-9/30/96).
Childhood asthma: An AHCPR-sponsored project by the American Academy of Pediatrics
examined variations in the care of acute asthma in pediatric practice as well as compliance with
national guidelines on asthma treatment. The project documented that pediatric providers are
generally compliant with national guideline recommendations for the care of children with acute
asthmatic exacerbations, although substantial variations from the guideline were noted for patients
with a moderate-to-severe presentation. Anthony Alario, Principal Investigator (Grant No.
HS07418; period: 9/30/92-9/29/94).
Pediatric gastroenteritis: An AHCPR-funded Pediatric Gastroenteritis Patient Outcomes Research
Project is examining treatment variations and outcomes for preschool children with pediatric
gastroenteritis in California, Georgia, and Michigan. Preliminary findings suggest that there may be
a significant amount of inappropriate care. Antibiotics were used in over a quarter of the episodes,
despite the fact that antibiotics are not recommended for conditions involving viral agents. On the
other hand, study findings suggest that oral rehydration may be underused. (Pediatric
Gastroenteritis: Treatment Patterns and Outcomes Among Disadvantaged Children. Part of the
Pediatric Gastroenteritis Patient Outcomes Research Project. Contract No. 282-90-0043.)
Family-centered care: A recent study attempted to determine whether an intervention program that
involves children, parents, and physicians in treatment decisions for children with chronic disease
improves the health status of children, as shown by both clinical variables and self-reports. Sherrie
H. Kaplan, Principal Investigator (Grant No. HS06897; period: 9/30/91-12/31/95).
Adolescent health: An AHCPR study published in the Journal of the American Medical
Association identifies how providers can encourage urban adolescents to seek and receive
preventive and primary care. According to the adolescents interviewed for the study, the most
important provider characteristics are provider hand-washing, clean instruments, honesty, respect
toward teens, cleanliness, know-how, carefulness, experience, seronegativity for HIV, equal
treatment of all patients, and confidentiality (Ginsburg, Slap, Cnaan, et al., 1995).
Physician fees: Recent research based on the 1987 National Medical Expenditure Survey (NMES)
found that children in States with higher Medicaid physician fees were more apt to receive their
care from physicians than in more expensive hospital-based facilities, and therefore total
expenditures for children in the most generous physician fee States were only about three-fourths of
those in the least generous States (Cohen and Cunningham, 1995).
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Febrile infants: A current project is researching variations in diagnosis and treatment of infants
with high fevers among office-based pediatricians across the country, and how these differences
affect outcomes and costs. Robert H. Pantell, Principal Investigator (Grant No. HS06485; period:
5/l/93-l/31/98).
Sickle cell disease: An AHCPR-supported guideline released in 1993 recommends screening of all
newborn babies for sickle cell disease and for those who test positive, the administration of
protective doses of penicillin (Smith, Kinney, Ames, et al., 1993).
Cancer prevention for minority women: In a randomized controlled trial, investigators assessed
the impact of a system of periodic feedback and financial incentives on physician compliance with
cancer screening guidelines in HealthPASS, Philadelphia’s Medicaid HMO. The study found that
providing feedback and bonuses to primary care sites did not significantly improve primary care
provider attention to cancer prevention for minority women over 50. Alan L. Hillman, Principal
Investigator (Grant No. HS07720; period: 9/30/93-9/29/96).
Assuring quality services: In recent years, the research community as well as public and private
payers have focused a lot of attention on development of instruments and mechanisms for
monitoring the quality of care. Most of these efforts have focused on adults. A 1995 AHCPR
workshop for State Medicaid directors and other senior State officials, "Assuring Quality Services
for Children: Opportunities and Challenges in a Changing Health Care System," was designed to
help States find or design the tools and systems they need to assure quality of care for children.
Pediatric specialists: AHCPR is sponsoring research on the effects of resources used and quality of
care of referrals to pediatric specialists compared to adult specialists for common and uncommon
conditions among Medicaid children. James M. Perrin, Principal Investigator (Grant No. HS09416;
period: 9/30/96-9/29/98).
 Early Discharge: Maternal and Infant
Journal of Health Affairs 1997
N=5,201 Women Who Gave Birth In 1995
• Of 3,130 women released from hospital in <24 hours
- 64% said it was too short
- 33% said it was just right
- 3% said it was too long
* 95% willing to go home after 24 hours next time if home care
provided
• Of 1,833 women released 25-48 hours post delivery
- 48% said too short
- 49% said just right
- 3% said too long
* 90% willing to go home in 24 hours with home care
• Of 238 women who stayed in hospital > 48hours
- 24% said too short
- 69% said just right
- 6% said too long
* 91% willing to go home in 24 hours with home care
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 A randomized clinical trial of early hospital discharge and home follow-up of very low birth
weight infants concluded: with follow-up care in the home by a nurse specialist, early discharge
is safe and cost effective. The net savings was $18,580 for each infant (N. England J. Med.
1986; 315:934-9)
 The average cost per month for a low-birthweight baby in hospital is $26,190 whereas the cost
per month for a low-birthweight baby in home care is $330. The savings per month for a lowbirthweight baby using home care is $25,860. Olsten Kimberly Quality Care, 1996.
 Caring for low-birthweight babies in the NICU tends to be the most expensive aspect of
pediatric services for payers and MCOs . The estimated annual cost of caring for infants in the
neonatal intensive care unit nationally is $8 billion. The average cost of caring for one low
birthewight infant in the NICU is $72,000. Transitioning neonates from the NICU to home
could save an average of $20,000 per case. The Remington Report, Feb/March 1995.
 An infant born with breathing problems and feeding problems will accrue $60,970 in hospital
care whereas home care would cost $20,209 ~ a savings of $40,761. To treat an infant requiring
antibiotic infusions would cost $7,290 in hospital and $2,070 in home care ~ a savings of
$5,220. Aetna Life and Casualty Co, May 28, 1984, Business Week Magazine and OTA May
1987 report, “Technology Dependent Children: Hospital v. Home Care, A Technical
Memorandum”.
 NICU Graduation – Approximately 2,700,000 in hospital charges ($10,609 per infant discharge)
and an estimated 2,073 days of hospital care were saved during a 7-month study. 257 study
infants discharged “early” through a University of Cincinnati program from a neonatal intensive
care unit (NICU) were compared to 477 control infants discharged during a prior 1-year period.
Significantly earlier discharge of high-risk neonates produced a decrease in hospital charges
without causing excessive morbidity. The reduction in hospital charges was 30 times higher
than program expenses. (J Pediatrics 1995; 127:285-90).
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 Cost per month of hospital care compared to home care, selected conditions.
Condition
a. Infant born with breathing and
feeding problems
b. Neurological disorder with
respiratory problems
c. Quadriplegic patient with spinal
cord injury
d. Cerebral palsy patient
e. Ventilator-dependent patient care
f. Nutrition infusions
g. Antibiotic infusions
h. Patient requiring respiratory support
Cost of Hospital
Care
$60,970
Cost of
Home Care
$20,209
Dollar
Savings
$40,761
$17,783
$196*
$17,587
$23,862
$13,931
$9,931
$8,425
$22,569
$23,670
$7,290
$24,715
$4,867**
$1,766
$9,000
$2,070
$9,267
$3,558
$20,803
$14,670
$5,220
$15,448
* After initial cost of equipment
** In extended care unit of hospital
Sources: (a-d) Aetna life and Casualty Co, May 28, 1984, Business Week Magazine, (e) American Association
for Respiratory Therapy, February 1984; (f) The Wall Street Journal, July 18m 190 (g-h) OTA May
1987 report, “Technology Department Children: Hospital v. Home Care, A Technical
Memorandum”
Figure 1: Reductions in Average NICU LOS: Preliminary PHMS
Outcomes in 4 Markets
(Reductions range from 12.4 to 24.2%, averaging 15.5%)
3 0 .0 %
2 6 .0 %
2 5 .0 %
1 9 .7 %
1 8 .9 %
1 9 .3 %
2 0 .0 %
1 5 .0 %
1 6 .5 %
1 6 .3 %
1 6 .1 %
1 6 .1 %
1 4 .2 %
1 4 .1 %
1 0 .0 %
5 .0 %
0 .0 %
M a rk e t A
M a rk e t B
M a rk e t C
His to ric a l LO S
M a rk e t D
Ac tua l P HM S LO S
Source: Healthcare Demand and Disease Management – October 1997, pg. 149
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 The average LOS for newborns requiring antibiotic therapy decreased by 5 days for those who
were referred to home IV therapy following release from NICU. The average cost of home IV
therapy was $1,821 whereas the average cost per patient for hospital was $4,860 and the
average cost of savings per patient was $3,039. A study conducted by Cook and Sabo (Nurses
for Healthy Newborns, Inc.) and Lasley (Yale-New Haven Hospital), 1995.
 Custom home care programs, such as home apnea monitoring, would benefit populations with
unique requirements. Home apnea monitoring detects the cessation of breathing in babies at
high risk for SIDS. SIDS deaths account for 40% - 60% of infant deaths that occur during the
first few weeks of life. Perinatal Home Care News, April 1996, Vol. 2(2).
 Retrospective study looks at 31 newborns (less than 30 days of age) from 11/1/92 to 8/30/94
referred to Nurses for Healthy Newborns Inc. (NHN), for home IV therapy. The average length
of stay (LOS) was reduced 5 days per patient, with an average savings of $3,039 per patient.
There were no complications or readmissions. (Linda Cook RNC, BSN, NNP, Marie O. Sabo,
RN, CLE (NHN) and Laura K. Lasley, MD (Yale-New Haven Hospital)
 Niche home care providers have clinical and cost advantages over traditional home care
agencies. Hidden costs of utilizing non-specialized home care agencies, re-hospitalization,
over utilization of services and slower discharge from acute care units impede managed care
payers from receiving the best value for their home care dollar. Perinatal Home Care News,
April 1996, Vol. 2(2).
Pediatric Health Management:
 Approximately 7% of U.S. births are preterm. In addition to physical limitations, a preterm
infant is threatened by psychosocial disruptions related to inadequate opportunities for
attachment, separation from parents, and altered development processes. JOGNN Vol 23(1).
 Having a preterm infant is a stressful experience for the parents. Researchers have discovered
that even with early contact and unlimited visiting, parental stress levels remain high, although
most parents believe their presence is helpful for the infants. Not only must parents cope with
stress of their preterm infant, but they are also exposed to further stress over a long period of
time. Most preterm infants do not progress smoothly in their recovery and continuance of
medical problems causes uncertainty and confusion for the parents. JOGNN Vol 23(1).
 As the infant is discharged, parents need assistance in learning to assume responsibility for
infant care. Hospital discharge and integrating the infant into the home are stressful times for
parents. Brown and Bakeman (1980) studied preterm infants during the early post-discharge
period and found they were more difficult to care for and less interactive than full term infants.
JOGNN Vol 23(1).
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 Parent Line: Nurse Telephone Intervention for Parents and Caregivers of Children from Bith
Through Age 5; Mary Lou Moore, PhD, CCE, FAANMS and Heidi Krowchuk PhD, PHP;
Journal Society of Pediatric Nursing; Vol. 2, No. 4, 179-184, December, 1997: The telephone
can be of value to pediatric nurses in providing health teaching, and support to patients.
 Childhood Immunizations
 Healthy people 2000: Goal 90%
 National average 1995: 75%
 NCQA Quality Compass: 78.6%
 NCQA New England: 89%
 NCQA South Central: 73%
 Immunizations save lives and reduce health care related costs for avoided disease. Infant
mortality rates have declined over the past decade to 7.2/1000 live births in 1996, with the
Centers for Disease Control and Prevention attributing about 1/3 of the decline to a 15% decline
in Sudden Infant Death Syndrome (SIDS).
 Pediatric HIV/AIDS (1997)
 90% of children under 12 with AIDS infected perinatally
 94% of 223 patients at Ryan White centers: $1237 +/- $1751 in medication per patient (90day period)
 Annual average use of children with AIDS: 1.4 hospitalizations, 16 IP days, 2 ER visits, 18
OP visits, 15 home visits
 Annual medical cost of pediatric AIDS case: $37,928
 Annual health care cost of pediatric HIV positive case: $9,382
 HIV Prevention
 Protocol 076= administer Zidovudine during pregnancy, labor, delivery, and newborn
period; reduces transmission from 25.5% to 8.3%
 Counseling HIV positive mothers against breastfeeding: decreases transmission between 10
and 18%
 Protocol 076 treatment for hypothetical group of 100 pregnant, HIV-positive women and
their infants costs $104,502
- Reduction in pediatric HIV cases results in cost savings of $1,701,333
- Net cost savings: $1,596,831
 Congenital Syphilis (CS) (1998)
 Average hospital charge for 85 infant CS cases in Maryland study: $3,191 with ALOS 10
days
 Prevention: penicillin prevents fetal infection if given in first trimester; usually prevents
infection if administered before last month of pregnancy
 Hepatitis B (1998)
 The 4.8% lifetime risk of becoming infected with HB virus is reduced by 68% with infant
vaccination and by 45% with adolescent vaccination
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 Pediatric Injury
 1995: 266,000 children age 0-14 hospitalized for unintentional injury
 $1 billion in costs
 28% paid for by public sources
 Falls account for 36% of hospitalizations
 Motor vehicle accidents: 19%
 25% of US children experience medically attended injury annually
 44% in the home (28% falls, 34% struck or cut)
 Significant variation in rates by pediatric age category (high rates of fatal burns among ages
1-4)
 Pediatric Injury: Intervention and Prevention Strategies
 Home environment assessment: water temperature, likely areas of falling, other safety and
prevention measures
 Effective education regarding window guards and risks to children in homes of two or more
stories, helmet use, proper car seat and seat belt use
 Helmets, car seat use/incentives
Child Abuse:
 Multiple short and long term costs
 Home visiting by trained laypersons usually referred to as outreach workers
 Home visiting for prenatal infant and child care helps prevent antisocial behavior, JAMA, 1998.
 The National Maternal and Infant Health Survey study provides evidence that fully breastfed
babies for six months has a positive impact on health. Raisler J et al. Breastfeeding and Infant
Illness; a Dose Response Relationship? Am J Public Health 1999 Jan; 89: 25-30.
 This study supports the use of antenatal steroids in preterm labor or premature rupture of
membranes without growth retardation. However, for women with pregnancy induced
hypertension and fetal growth retardation, there may be little benefit and increased risk for
neonatal sepsis. Elimian A et al. Effectiveness of Antenatal Steroids in Obstetrics Subgroups.
Obstet Gynecol 1999 Feb; 93: 174-9.
Pediatric Asthma
 The NIAID study in 1997 is the largest study ever completed on children, 1,500 ages 4-11. The
study concluded that morbidity was related to environmental exposures and could be reduced by
eliminating or reducing exposure to passive smoking and indoor allergens, i.e., cockroaches,
dust mites, cat allergens, etc. Other factors include psychological problems, access to care and
appropriate medications. Still the study showed that education combined with environmental
and behavioral interventions results in significant reductions in symptoms and doctor visits.
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 Virginia Health Outcomes Partnership (VHOP) established a disease management service for
fee for service (FFS) primary care case management for low-income kids and adult asthmatics.
Claims for emergency department (ED) visits decreased 7% in intervention communities, with
increased dispensing of inhalers and nebulizers (25%). A cost effectiveness analysis revealed a
direct program savings of $3 to $17 for each dollar spent (1997).
 A study performed by Kaiser Permanente of Northern California looked at outpatient
management practices associated with reduced risk of pediatric asthma hospitalizations.
Individuals having a written asthma management plan were associated with having reduced
odds of hospitalizations. Having a written asthma management plan and starting or increasing
medications at the onset of cold or flu were associated with reduced odds of making an ED visit
(1997).
 An 18-month National Survey conducted by Olsten Health Services reported asthma
management programs can lead to cost savings over $11,500 per patient; decreasing incidence
and severity of attacks; 2/97; “Continuing Case Management”.
 A randomized comparison of cost-effectiveness of guided self-management and traditional
treatment of asthma in Finland reported a 68% reduction in lost time from work and total cost
22% lower for the self-management group (4/98, BMJ).
 Other research is in the process of being compiled and will be added on a quarterly basis.
Other References and citations:
1. National Center for Health Statistics. (1996). Healthy people 2000 review 1995-96.
(DHHS Publication No. PHS 96-1256). Hyattsville, MD: Public Health Service.
2. Maternal and Child Health Bureau. (1997). Performance outcomes. Health Resources
and Services Administration, U.S. Department of Health and Human Services.
3. Healthplan Employer Data and Information Set (HEDIS 3.0)
4. Cassady C, Farel A, Guild P, Kennelly J, Peoples-Sheps M, Potrzebowski P, and Waller
C. Maternal and Child Health Model Indicators (1997). Chapel Hill: University of North
Carolina, School of Public Health.
5. U. S. Preventive Services Task Force. (1996). Guide to clinical preventive services. (2nd
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6. Oliva G, Milder T, Miller PM, Greene J, Sobozinsky I, and Cosand NL. Selecting health
indicators for public health surveillance in a changing health care environment. (1997).
San Francisco: University of California San Francisco: Family Health Outcomes Project.
7. Bureau of Vital Records. Utah's vital statistics: Births and Deaths. (1970-1996). Utah
Department of Health: Office of Public Health Data.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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8. Division of Community and Family Health Services. Maternal and infant health in Utah.
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U.S. Department of Health and Human Services: Centers for Disease Control and
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South Carolina, Department of Health and Environmental Control.
15. Reproductive Health Team. Entry into prenatal care for live births in Utah, 1992-1994.
(1996). Salt Lake City: Utah Department of Health, Division of Community and Family
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20. Robinson DV. (1997, April). (Internet web page news release
http://www.cigna.com/newsroom/ news/ n970430.html). Results from CIGNA's healthy
babies program leave company tickled pink...and blue: prenatal care program eliminated
potential costs of $2.4 million. Philadelphia: CIGNA Corporation.
21. Altfeld, S, Handler, A, Burton D, Berman, L. (1997). Wantedness of pregnancy and
prenatal health behaviors. Women and Health. 26(4), 29-43.
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22. Institute of Medicine. Brown SS and Eisenberg L. (Eds.) (1995). The best intentions:
unintended pregnancy and the well-being of children and families. Washington DC:
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24. McCaw-Binns A, LaGrenade J, and Ashley, D. (1995, April). Under-users of antenatal
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attenders. Social Science and Medicine. 40(7),1003-12.
25. Institute of Medicine. (1988). Preventing low birth weight. Washington D.C.:National
Academy of Sciences.
26. Joyce T, Racine AP, McCalla S, and Wehbeh H. (1995, June). The impact of prenatal
exposure to cocaine on newborn costs and length of stay. Health Services Research.
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27. American College of Obstetricians and Gynecologists. (1993). Technical bulletin number
180 - May 1990. International Journal of Gynecology and Obstetrics. 43,75-81.
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attributable to cigarette smoking during pregnancy - United States, 1995. Morbidity and
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29. Eisenberg A, Murkoff HE, and Hathaway, SE. (1988). What to expect when you're
expecting. New York: Workman Publishing.
30. Armstead RC and Gorman JK. (1995, September/October). Baby love and budget relief:
some promising practices in prenatal managed care in Medicaid. Journal of American
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31. Atrash HK. (1995, September/October). Not all prenatal care is appropriate care. Journal
of American Medical Women's Association. 50(5), 144-145.
32. Calhoun BC, Watson PT. (1991, November).The cost of maternal cocaine abuse:I the
perinatal cost. Obstetrics and Gynecology. 78(5), 731-734.
33. Abel EL and Sokol RJ. (1991, May/June). A revised conservative estimate of the
incidence of FAS and its economic impact. Alcoholism: Clinical and Experimental
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35. Alexander GR and Kotelchuck M. (1996, September/October). Quantifying the adequacy
of prenatal care: A comparison of indices. Public Health Reports. 111,408-418.
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Evidence of Cost Savings & Improved Outcomes: Maternal & Pediatric Health Management
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36. Institute of Medicine. (1985). Prenatal care: Reaching mothers, reaching infants.
Washington D.C.:National Academy of Sciences.
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