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Receipt of Well-Baby Care -- Maine, 1988-1992

Routine well-baby care (i.e., nonillness-related visits to a health-care professional during infancy) provides important opportunities to promote health in infants through timely receipt of recommended vaccinations, detection and treatment of diseases, and identification of potential developmental or psychosocial disorders. * In Maine, although well-baby services are provided as a component of the state's maternal and child health programs, the extent to which parents in Maine use public and private sources of such services and adhere to American Academy of Pediatrics guidelines has not been well characterized. This report uses data from Maine's Pregnancy Risk Assessment Monitoring System (PRAMS) to characterize the levels of well-baby care in Maine during 1988- 1992.

PRAMS is a CDC-developed, population-based surveillance system used in 13 states ** and the District of Columbia. PRAMS uses data from birth certificates and from self-reported behavioral surveys of mothers 3-6 months after delivery (2). In Maine, a stratified systematic sample of 100-200 new mothers is selected each month from birth certificates; mothers delivering infants of low birthweight (LBW) (less than 2500 g {5 lb 8 oz} at birth) are oversampled.

Of 5807 residents who gave birth in Maine from June 1988 through May 1992, 4799 (82.6%) responded. Exclusion categories comprised infants who had been hospitalized more than 7 nights after birth or who had died during the interval preceding the survey (n=913), infants who were older or younger than age 3-6 months at the time of the survey (n=779), and infants whose birthweights were unknown or whose mothers did not provide information about the number of visits to a health-care professional (n=359).

Respondents were asked, "How many times has your baby been to a doctor or nurse for baby shots or routine well baby care?" Infants were classified as having had a low level of well-baby care if they were aged 3-4 months and had had no nonillness-related visits to a health-care professional or were aged 5-6 months and had had fewer than two visits. Infants were classified as having had a high level of care if they were aged 3-4 months and had had three or more nonillness-related visits or were aged 5-6 months and had had four or more such visits. All other infants were classified as having had a "usual" level of care. The PRAMS questionnaire also asked about 1) the planning status of the pregnancy; 2) sources of family income; 3) initiation of prenatal care; and 4) knowledge of the mother (before hospital discharge) about where to obtain medical care if the infant should become ill. Birth certificates were used to obtain information about the mother's education, age, marital status, birth interval, and parity; the infant's birthweight and birth date; and the number of prenatal-care visits for that pregnancy. Adequacy of prenatal care was calculated by the Kessner Index, which provides a multidimensional measure that incorporates when prenatal care began, the total number of prenatal visits made by the mother, and the gestational age of the baby (3). Data were weighted to account for survey design and nonresponse. Confidence intervals (CIs) were calculated using the standard errors estimated by SUDAAN (4).

Of 2024 mothers who gave birth to normal birthweight infants, 22 (1.1%; 95% CI=0.7%-1.5%) reported having had a low number of well-baby-care visits; 895 (44.0%; 95% CI=41.8%-46.2%), a usual number of visits; and 1107 (54.9%; 95% CI=52.7%-57.1%), a high number of visits (Table_1). Of the 724 mothers who gave birth to LBW infants, 13 (1.9%; 95% CI=1.3%-2.5%), reported having had a low number of visits; 238 (33.0%; 95% CI=30.8%-35.2%), a usual number of visits; and 473 (65.1%; 95% CI=62.7%-67.5%), a high number of visits (Table_2).

The level of well-baby care differed statistically by birthweight group. Compared with normal birthweight infants, LBW infants were less likely to receive a usual level of care, 1.2 times as likely to receive a high level, and 1.7 times as likely to receive a low level. For mothers of LBW infants, income from government aid was the only characteristic statistically associated with a low level of care (p less than 0.04). Mothers of LBW infants whose pregnancies were unwanted were less likely to obtain a high level of care than were those whose pregnancies were intended. Levels of well-baby care did not differ statistically within birthweight group in relation to other factors (i.e., education, family income from employment, adequacy of prenatal care, and knowledge of source of pediatric care).

Reported by: JA Danna, MPH, EM Naor, MA, R Curtis, Z Koppanyi, MD, Maine Dept of Human Svcs. Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Although state and territorial health departments monitor maternal and child health status, the receipt of well-baby- care services in the United States has not been characterized. The findings in this report indicate that most (98%-99%) women who gave birth in Maine during 1988-1992 reported having obtained a usual or high number of well-baby-care visits during the early postpartum period (i.e., up to 6 months after birth). This high level may reflect at least four features of the maternal and infant health program in Maine. First, Medicaid eligibility for infants aged 0-1 year is at the maximum state-designated level -- 185% of the federal poverty level. Second, approximately 60% of primary-care physicians in Maine participate in the state Medicaid Preventive Health Program *** (D. Curtis, Maine Department of Human Services, personal communication, 1993). Third, Maine provides routine vaccination coverage to all state residents; providers may charge no more than a $2 administrative fee per vaccination for children. Fourth, information provided to parents during home visits by community and public health nurses emphasizes the importance of well-baby care.

The findings in this report are subject to at least three limitations. First, because the information about quantity of well-baby visits was self-reported, respondents may have counted sick-baby visits in their totals. Second, the substantial proportion of LBW infants who received high levels of care may reflect the routine close monitoring of LBW infants (CDC, unpublished data, 1993). Third, because the number of normal birthweight and LBW infants with low levels of care (22 and 13, respectively) was small, this analysis must be interpreted with caution.

PRAMS provides a means for state program managers to investigate behaviors related to seeking infant care and to monitor and assess their efforts toward achieving the year 2000 national health objective of increasing to at least 90% the proportion of infants aged less than or equal to 18 months who receive recommended primary-care services at the appropriate intervals (objective 14.16) (5). In addition, in Maine and other states, PRAMS provides data about early infancy-care levels that can serve as a baseline for program planning and development.

References

  1. Hoekelman RA. Child health supervision. In: Primary pediatric care. 2nd ed. St. Louis: Mosby Year Book, 1992.

  2. Adams MM, Shulman HB, Bruce C, Hogue C, Brogan D. The Pregnancy Risk Assessment Monitoring System: design, questionnaire, data collection, and response rates. Paediatr Perinat Epidemiol 1991;5:333-46.

  3. Kessner DM, ed. Contrasts in health status. Vol 1. Infant death: an analysis by maternal risk and health care. Washington, DC: Institute of Medicine/Academy of Sciences, 1973.

  4. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for Survey Data Analysis (SUDAAN) version 6.20 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

* In 1967, the American Academy of Pediatrics established guidelines for the frequency and timing of well-baby visits (1); these guidelines were revised in 1988. 

** Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan, New York, Oklahoma, South Carolina, Washington, and West Virginia. 

*** Maine's version of the federally mandated Early and Periodic Screening Diagnosis and Treatment program.
Table_1
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TABLE 1. Percentage * of normal birthweight infants + aged 3-6 months receiving
well-baby care, by level of care & and selected characteristics of mother -- Maine,
Pregnancy Risk Assessment Monitoring System, 1988-1992
==============================================================================================================================
                                                    Level of care
                                 ---------------------------------------------------
                                   Low (n=22)      Usual (n=895)      High (n=1107)
                                 ---------------  ---------------    ---------------
 Characteristic                   %     (SE @)     %      (SE)        %      (SE)
------------------------------------------------------------------------------------
 Education (yrs)
    <12                           **     --       44.3  (+/- 3.3)    54.4  (+/- 3.3)
   >=12                          1.0  (+/-0.2)    44.3  (+/- 1.1)    54.8  (+/- 1.2)
 Age group (yrs)
    <20                           **     --       41.3  (+/- 3.5)    57.3  (+/- 3.6)
   >=20                          1.0  (+/-0.2)    44.5  (+/- 1.1)    54.4  (+/- 1.1)
 Marital status
   Married                       1.2  (+/-0.3)    45.4  (+/- 1.2)    53.4  (+/- 1.2)
   Unmarried                      **     --       40.2  (+/- 2.4)    59.2  (+/- 2.4)
 Parity
   Primiparous                   0.6  (+/-0.3)    37.8  (+/- 1.6)    61.6  (+/- 1.6)
   Multiparous                   1.3  (+/-0.3)    49.2  (+/- 1.4)    49.5  (+/- 1.4)
 Birth interval (yrs) ++
    <2                            **     --       51.2  (+/- 4.3)    47.0  (+/- 4.3)
   2-4                           1.0  (+/-0.4)    47.5  (+/- 1.8)    51.5  (+/- 1.8)
   >=5                            **     --       53.7  (+/- 3.0)    44.8  (+/- 3.0)
 Planning status of pregnancy
   Intended                      1.2  (+/-0.3)    44.0  (+/- 1.4)    54.8  (+/- 1.4)
   Mistimed                       **     --       43.4  (+/- 2.1)    55.8  (+/- 2.1)
   Unwanted                       **     --       47.1  (+/- 4.0)    52.2  (+/- 4.0)
   Don't know                     **     --       46.5  (+/- 4.8)    50.9  (+/- 4.8)
 Sources of family income
   Employment
     Yes                         1.1  (+/-0.2)    44.5  (+/- 1.2)    54.5  (+/- 1.2)
     No                           **     --       42.1  (+/- 3.2)    56.7  (+/- 3.2)
   Government aid
     Yes                          **     --       39.1  (+/- 2.3)    59.9  (+/- 2.3)
     No                          1.1  (+/-0.3)    45.7  (+/- 1.2)    53.2  (+/- 1.2)
   Other &&
     Yes                         1.1  (+/-0.5)    44.8  (+/- 2.3)    54.2  (+/- 2.3)
     No                          1.1  (+/-0.3)    44.0  (+/- 1.2)    54.9  (+/- 1.2)
 Adequacy of prenatal care @@
   Adequate                      0.9  (+/-0.2)    43.7  (+/- 1.2)    55.4  (+/- 1.2)
   Intermediate                  1.9  (+/-0.7)    46.6  (+/- 2.5)    51.6  (+/- 2.5)
   Inadequate                     **     --       37.7  (+/- 5.6)    62.4  (+/- 5.6)
 Knowledge of source
  of pediatric care ***
   Yes                           0.8  (+/-0.3)    44.5  (+/- 1.4)    54.7  (+/- 1.4)
   No                             **     --       54.1  (+/-12.6)    45.9  (+/-12.6)

 Total                           1.1  (+/-0.2)    44.0  (+/- 1.1)    54.9  (+/- 1.1)
------------------------------------------------------------------------------------
  * Percentages weighted to account for survey design and nonresponse; totals may not add to 100% because of rounding.
  + >=2500 g (5 lb 8 oz) at birth; n=2024.
  & Low level = infants aged 3-4 months who had had no nonillness-related visits to a health-care professional or infants
    aged 5-6 months who had had fewer than two such visits. High level = infants aged 3-4 months who had had three or
    more nonillness-related visits or infants aged 5-6 months who had had four or more such visits. Usual level = all other
    infants.
  @ Standard error.
 ** Numbers too small for meaningful analysis.
 ++ Applies to multiparous mothers only. Sample size of infants receiving low levels of care was 13; usual levels, 573; and
    high levels, 568.
 && Includes unemployment compensation, alimony, Social Security benefits, and other sources.
 @@ Adequacy calculated by the Kessner Index, which provides a multidimensional measure that incorporates when prenatal
    care began, the total number of prenatal visits made by the mother, and the gestational age of the baby (3).
*** Measurement of knowledge before being discharged from hospital (after giving birth) of how to obtain health care if
    the infant should become ill. Data available for 1990-1992 only. Sample size of infants receiving low levels of care was
    10; usual levels, 531; and high levels, 646.
==============================================================================================================================




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Table_2
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Percentage * of low-birthweight (LBW) infants + aged 3-6 months receiving
well-baby care, by level of care & and selected characteristics of mother -- Maine,
Pregnancy Risk Assessment Monitoring System, 1988-1992
==============================================================================================================================
                                                    Level of care
                                 --------------------------------------------------
                                   Low (n=13)      Usual (n=238)      High (n=473)
                                 --------------   ---------------    --------------
 Characteristic                   %     (SE @)     %      (SE)        %      (SE)
-----------------------------------------------------------------------------------
 Education (yrs)
    <12                          3.0  (+/-0.9)    33.4  (+/-2.4)     63.6  (+/-2.5)
   >=12                          1.5  (+/-0.3)    33.3  (+/-1.3)     65.2  (+/-1.3)
 Age group (yrs)
    <20                          **      --       37.6  (+/-3.2)     58.8  (+/-3.2)
   >=20                          1.6  (+/-0.3)    32.4  (+/-1.2)     66.1  (+/-1.2)
 Marital status
   Married                       1.9  (+/-0.4)    32.7  (+/-1.3)     65.4  (+/-1.4)
   Unmarried                     **      --       34.4  (+/-2.1)     63.7  (+/-2.1)
 Parity
   Primiparous                   1.4  (+/-0.4)    30.2  (+/-1.5)     68.5  (+/-1.6)
   Multiparous                   2.5  (+/-0.6)    36.5  (+/-1.7)     61.1  (+/-1.7)
 Birth interval (yrs) ++
    <2                           **      --       43.9  (+/-3.8)     53.3  (+/-3.8)
   2-4                           **      --       35.4  (+/-2.3)     62.3  (+/-2.3)
   >=5                           **      --       31.7  (+/-3.0)     65.7  (+/-3.1)
 Planning status of pregnancy
   Intended                      **      --       32.1  (+/-1.5)     67.0  (+/-1.5)
   Mistimed                      **      --       34.1  (+/-2.4)     63.4  (+/-2.4)
   Unwanted                      **      --       40.2  (+/-4.5)     56.9  (+/-4.6)
   Don't know                    **      --       29.5  (+/-3.4)     65.0  (+/-3.6)
 Sources of family income
   Employment
     Yes                         1.6  (+/-0.3)    32.8  (+/-1.2)     65.6  (+/-1.3)
     No                          **      --       34.6  (+/-2.7)     62.3  (+/-2.7)
   Government aid
     Yes                         3.8  (+/-0.8)    38.8  (+/-2.1)     57.4  (+/-2.1)
     No                          **      --       30.1  (+/-1.3)     69.0  (+/-1.3)
   Other &&
     Yes                         **      --       27.5  (+/-2.1)     70.3  (+/-2.1)
     No                          1.8  (+/-0.4)    35.3  (+/-1.3)     63.0  (+/-1.4)
 Adequacy of prenatal care @@
   Adequate                      1.9  (+/-0.4)    34.7  (+/-1.4)     63.3  (+/-1.4)
   Intermediate                  **      --       30.4  (+/-2.2)     67.6  (+/-2.2)
   Inadequate                    **      --       27.8  (+/-3.8)     70.4  (+/-3.9)
 Knowledge of source
  of pediatric care ***
   Yes                           1.7  (+/-0.4)    37.1  (+/-1.5)     61.2  (+/-1.6)
   No                            **      --        **      --         **      --

 Total                           1.9  (+/-0.3)    33.0  (+/-1.1)     65.1  (+/-1.2)
 ----------------------------------------------------------------------------------
  * Percentages weighted to account for survey design and nonresponse; totals may not add to 100% because of rounding.
  + <2500 g (5 lb 8 oz) at birth; n=724.
  & Low level = infants aged 3-4 months who had had no nonillness-related visits to a health-care professional or infants
    aged 5-6 months who had had fewer than two such visits. High level = infants aged 3-4 months who had had three or
    more nonillness-related visits or infants aged 5-6 months who had had four or more such visits. Usual level = all other
    infants.
  & Standard error.
 ** Numbers too small for meaningful analysis.
 ++ Applies to multiparous mothers only. Sample size of infants receiving low levels of care was eight; usual levels, 128;
    and high levels, 221.
 && Includes unemployment compensation, alimony, Social Security benefits, and other sources.
 @@ Adequacy calculated by the Kessner Index, which provides a multidimensional measure that incorporates when prenatal
    care began, the total number of prenatal visits made by the mother, and the gestational age of the baby (3).
*** Measurement of knowledge before being discharged from hospital (after giving birth) of how to obtain health care if
    the infant should become ill. Data available for 1990-1992 only. Sample size of infants receiving low levels of care was
    seven; usual levels, 154; and high levels, 251.
==============================================================================================================================



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