Defining equity in health.

STUDY OBJECTIVE: To propose a definition of health equity to guide operationalisation and measurement, and to discuss the practical importance of clarity in defining this concept. DESIGN: Conceptual discussion. Setting, Patients/Participants, and Main results: not applicable. CONCLUSIONS: For the purposes of measurement and operationalisation, equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage-that is, wealth, power, or prestige. Inequities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant with and closely related to human rights principles. The proposed definition of equity supports operationalisation of the right to the highest attainable standard of health as indicated by the health status of the most socially advantaged group. Assessing health equity requires comparing health and its social determinants between more and less advantaged social groups. These comparisons are essential to assess whether national and international policies are leading toward or away from greater social justice in health.

The relationship of neighborhood socioeconomic characteristics to birthweight among 5 ethnic groups in California.

OBJECTIVES: This study sought to examine relationships between neighborhood socioeconomic characteristics and birthweight, accounting for individual socioeconomic characteristics, among 5 ethnic groups. METHODS: Birth records were linked to census block-group data for 22 304 women delivering infants at 18 California hospitals during 1994-1995. Information on income and additional factors was obtained from a surveyed subset of 8457 women. Neighborhood levels of poverty, unemployment, and education were examined. RESULTS: After adjustment for mothers' individual socioeconomic characteristics and other risk factors, less-favorable neighborhood socioeconomic characteristics were associated with lower birthweight among Blacks and Asians. No consistent relationship between neighborhood socioeconomic characteristics and birthweight was found among Whites, US-born Latinas, or foreign-born Latinas overall, but birthweight increased with less-favorable neighborhood socioeconomic characteristics among foreign-born Latinas in high-poverty or high-unemployment neighborhoods. These findings were not explained by measured behavioral or cultural factors. CONCLUSIONS: In addition to individual socioeconomic characteristics, living in neighborhoods that are less socioeconomically advantaged may differentially influence birthweight, depending on women's ethnicity and nativity.

A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge.

OBJECTIVE: Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother-infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother-infant pairs with postpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospital-based follow-up anchored in group visits. METHODS: We used a randomized clinical trial design with intention-to-treat analysis in an integrated managed care setting that serves a largely middle class population. Mother-infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based follow-up) or to the intervention arm (home nurse visit). Clinical utilization and costs were studied using computerized databases and chart review. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks postpartum. RESULTS: During a 17-month period in 1998 to 1999, we enrolled and randomized 1014 mother-infant pairs (506 to the control group and 508 to the intervention group). There were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or postpartum LOS. There were no differences with respect to neonatal LOS or Apgar scores. In the control group, 264 mother-infant pairs had an individual visit only, 157 had a group visit only, 64 had both a group and an individual visit, 4 had a home health and a hospital-based follow-up, 13 had no follow-up within 72 hours, and 4 were lost to follow-up. With respect to outcomes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeeding discontinuation, maternal depressive symptoms, or a combined clinical outcome measure indicating whether a mother-infant pair had any of the above outcomes. However, mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother-infant pair; the cost of an individual 15-minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $92. CONCLUSIONS: For low-risk mothers and newborns in an integrated managed care organization, home visits compared with hospital-based follow-up and group visits were more costly but achieved comparable clinical outcomes and were associated with higher maternal satisfaction. Neither strategy is associated with significantly greater success at increasing continuation of breastfeeding. This study had limited power to identify group differences in rehospitalization and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Measuring socioeconomic status/position in studies of racial/ethnic disparities: maternal and infant health.

OBJECTIVE: Theoretical and empiric considerations raise concerns about how socioeconomic status/position (abbreviated here as SES) is often measured in health research. The authors aimed to guide the use of two common socioeconomic indicators, education and income, in studies of racial/ethnic disparities in low birthweight, delayed prenatal care, unintended pregnancy, and breastfeeding intention. METHODS: Data from a statewide postpartum survey in California (N = 10,055) were linked to birth certificates. Overall and by race/ethnicity, the authors examined: (a) correlations among several measures of education and income; (b) associations between each SES measure and health indicator; and (c) racial/ethnic disparities in the health indicators "adjusting" for different SES measures. RESULTS: Education-income correlations were moderate and varied by race/ethnicity. Racial/ethnic associations with the health indicators varied by SES measure, how SES was specified, and by health indicator. CONCLUSIONS: Conclusions about the role of race/ethnicity could vary with how SES is measured. Education is not an acceptable proxy for income in studies of ethnically diverse populations of childbearing women. SES measures generally should be outcome- and population-specific, and chosen on explicit conceptual grounds; researchers should test multiple theoretically appropriate measures and consider how conclusions might vary with how SES is measured. Researchers should recognize the difficulty of measuring SES and interpret findings accordingly.

The validity of information on "race" and "Hispanic ethnicity" in California birth certificate data.

OBJECTIVE: To evaluate the validity of racial/ethnic information in California birth certificate data. DATA SOURCES: Computerized birth certificate data and postpartum interviews with California mothers. STUDY DESIGN AND DATA COLLECTION: Birth certificates were matched with face-to-face structured postpartum interviews with 7,428 mothers to compare racial/ethnic information between the two data sources. Interviews were conducted in Spanish or English during delivery stays at 16 California hospitals, 1994-1995. PRINCIPAL FINDINGS: The sensitivity of racial/ethnic classification in birth certificate data was very high (94 percent to 99 percent) for African Americans, Asians/Pacific Islanders, Europeans/Middle Easterners, and Latinas (Hispanics). For Native Americans, however, the sensitivity was only 54 percent. The positive predictive value of birth certificate classification of race/ethnicity was high for all racial/ethnic groups (96 percent to 97 percent). CONCLUSIONS: Despite limited training of birth clerks, the maternal racial/ethnic information in California birth certificate data appears to be a valid measure of self-identified race and Hispanic ethnicity for groups other than Native Americans.

Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors.

OBJECTIVE: This study, designed to avoid methodologic limitations of previous research, aimed to identify the important noninsurance barriers to timely prenatal care. METHODS: We identified a subsample of a cross-sectional statewide representative postpartum survey conducted in California during 1994-1995, focusing on 3071 low-income women with Medi-Cal or private coverage throughout pregnancy. RESULTS: Twenty-eight percent of those women had untimely care, although only 6% were unaware of their pregnancies during the first trimester. Controlling for numerous sociodemographic factors; knowledge, attitudes, beliefs, and behaviors; stressful life circumstances; and logistic obstacles that might deter seeking or receiving care, the following risk factors for untimely care were significant and experienced by more than one fifth of women: unwanted or unplanned pregnancy (affecting 43% and 66% of women, respectively), no regular provider before pregnancy (affecting 22% of women), and no schooling beyond high school (affecting 76% of women). Transportation problems, affecting 8% of women, appeared to be the only significant logistic barrier to timely care. CONCLUSION: Improving timeliness of prenatal care among low-income women with third-party coverage is likely to require broad social and health policies that focus on factors affecting women before pregnancy. Assistance with transportation could contribute to more timely care for some low-income women, but programs focusing primarily on other noninsurance barriers during pregnancy might not substantially improve the timeliness of care, at least among low-income women with third-party coverage.

A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge.

BACKGROUND: Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective. METHODS: We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother. Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum. RESULTS: Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120. CONCLUSIONS: For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Risk factors for late or no prenatal care following Medicaid expansions in California.

OBJECTIVES: To describe the characteristics and risk factors of women with only third-trimester (late) or no prenatal care. METHODS: A statewide postpartum survey was conducted that included 6364 low-income women delivering in California hospitals in 1994 and 1995. RESULTS: The following factors appeared most important, considering both prevalence and association with late or no care: poverty, being uninsured, multiparity, being unmarried, and unplanned pregnancy. Forty-two percent of women with no care were uninsured, and uninsured women were at dramatically increased risk of no care. Over 40% of uninsured women with no care had applied for Medi-Cal prenatally but did not receive it. Risks did not vary by ethnicity except that African American women were at lower risk of late care than women of European background. Child care problems were not significantly associated with either late or no care, and transportation problems (not asked of women with no care) were not significantly related to late care. CONCLUSIONS: Lack of insurance appeared to be a significant barrier for the 40% of women with no care who unsuccessfully applied for Medi-Cal prenatally, indicating a need to address barriers to Medi-Cal enrollment. However, lack of financial access is unlikely to completely explain the dramatic risks associated with being uninsured. In addition to eliminating barriers to prenatal coverage, policies to reduce late/no care should focus on pre-pregnancy factors (e.g., planned pregnancy and poverty reduction) rather than on logistical barriers during pregnancy.

The prevalence of low income among childbearing women in California: implications for the private and public sectors.

OBJECTIVES: This study examined the income distribution of childbearing women in California and sought to identify income groups at increased risk of untimely prenatal care. METHODS: A 1994/95 cross-sectional statewide survey of 10,132 postpartum women was used. RESULTS: Sixty-five percent of all childbearing women had low income (0%-200% of the federal poverty level), and 46% were poor (0%-100% of the federal poverty level). Thirty-five percent of women with private prenatal coverage had low income. Most low-income women with Medi-Cal (California's Medicaid) or private coverage received their prenatal care at private-sector sites. Compared with women with incomes over 400% of the poverty level, both poor and near-poor women were at significantly elevated risk of untimely care after adjustment for insurance, education, age, parity, marital status, and ethnicity (adjusted odds ratios = 5.32 and 3.09, respectively). CONCLUSIONS: This study's results indicate that low-income women are the mainstream maternity population, not a "special needs" subgroup; even among privately insured childbearing women, a substantial proportion have low income. Efforts to increase timely prenatal care initiation cannot focus solely on women with Medicaid, the uninsured, women in absolute poverty, or those who receive care at public-sector sites.

Clinical outcomes and maternal perceptions of an updated model of perinatal care.

BACKGROUND: Postpartum hospital stays seem likely to remain limited even under new laws which mandate that insurers cover 48-hour hospitalization after uncomplicated delivery. Clinicians, who are increasingly practicing in capitated arrangements, need better information to maximize clinical benefit to mothers and newborns using finite resources. OBJECTIVE AND INTERVENTIONS: This study's aim was to evaluate the clinical outcomes, patient perceptions, and costs of a revised model of perinatal care services. In this model, a new postpartum care center was established for routine follow-up of newborns within 48 hours after hospital discharge, educational efforts were shifted from the postpartum hospitalization to the prenatal period, and lactation consultant hours were increased. DESIGN AND PARTICIPANTS: Controlled, nonrandomized (double cohort) study that compared mothers and newborns with hospital stays of 48 hours or less during the Baseline Care (preintervention) study period (N = 344) with those under the Revised Care (postintervention) study period (N = 456). SETTING: The Hayward, California, medical center of Kaiser Permanente, a nonprofit health maintenance organization. DATA COLLECTION: Telephone interviews were attempted with all mothers 3 weeks after delivery. Data on rehospitalizations, emergency department (ED) and clinic visits, and costs during the first 14 postpartum days were collected from computerized databases and chart review. OUTCOME MEASURES: The combined clinical outcome was defined as any undesirable health event, including rehospitalization, an ED visit, or an urgent clinic visit by either the mother or newborn within the first 14 days postpartum, or breastfeeding discontinuation within the first 21 days postpartum. Maternal satisfaction and costs were also studied. RESULTS: Of 876 attempted interviews, 800 were completed (91%). Analyses were adjusted for age, race, education, parity, breastfeeding experience, and other relevant variables. Among the interviewed mother-newborn pairs, 45% in the Revised Care group experienced the combined clinical outcome, compared with 52% in the Baseline Care group. Newborns in the Revised Care group (29%) were significantly less likely to make urgent clinic visits during the first 14 days of life than those in the Baseline Care group (36%). There were no differences between groups in newborn ED visits or rehospitalizations, maternal clinical outcomes, or breastfeeding continuation. Mothers in the Revised Care group expressed higher satisfaction with the newborn's care, the amount of information they received about newborn care and breastfeeding, and the amount of help they received with breastfeeding. Planned hospital care, planned follow-up visits, and unplanned care costs decreased by $149 per delivery, while the new prenatal class and increased lactation consultant services cost $58 per delivery, for an estimated overall reduction in cost. CONCLUSIONS: We conclude that the revised model of perinatal care in this health maintenance organization medical center improved clinical outcomes and maternal satisfaction for low-risk mothers and newborns without increasing costs.