Are you spending your prenatal dollars wisely?

Study finds home monitoring of little value

Home uterine monitoring is a common prescription for high-risk pregnancies in this country. Monitoring, consultations with perinatal case managers, and prenatal education have been the backbone of many successful prenatal management programs developed by payers nationwide. However, a recent study in The New England Journal of Medicine finds that those efforts have little impact on preventing preterm labor in high-risk women.1

In fact, the study's authors concluded that high-risk women who had daily contact with a nurse, with or without home monitoring of uterine activity, had no better pregnancy outcomes than women who had weekly contact with a nurse. To determine whether home monitoring or frequent contact with a nurse had a positive impact on pregnancy outcomes, doctors at Kaiser Permanente Medical Center in Santa Clara, CA, studied 2,422 pregnant women with known risk factors for premature delivery.

All of the women received prenatal education. Participants then were placed randomly in one of three groups. Each group received one of the following interventions:

· weekly contact with a nurse;

· daily contact with a nurse;

· daily contact with a nurse and home monitoring of uterine activity.

No clear difference

The study concluded when the women reached 35 weeks of pregnancy or when they gave birth at less than 35 weeks. Results included the following:

1. Fourteen percent of the women in the weekly contact group gave birth at less than 35 weeks.

2. Thirteen percent in the daily contact group gave birth at less than 35 weeks.

3. Fourteen percent in the daily contact/home monitoring group gave birth at less than 35 weeks.

The percentages were closely related, indicating that the amount of contact made no difference in the outcomes of each group, researchers noted.

What causes women to have early deliveries has long been a question with no specific answers, notes Jay Iams, MD, of the Ohio State University College of Medicine in Columbus, in an editorial in the same issue of The New England Journal of Medicine.2 Reasons for early births can range from social to medical risk factors, and prematurity may be prevented, he adds.

Attitudes toward pregnancy must change

Professionals who have developed and implemented prenatal management programs have mixed reactions to the study's findings. Joy Hack, RN, BSN, CCE, prenatal coordinator for First Priority Health Blue Cross of Northeastern Pennsylvania in Wilkes-Barre, PA, says she is not surprised by the outcome of the study and agrees that the attitude toward pregnancy in this country must change. She says an important first step is for Americans to take pregnancy more seriously. "Our society has to take a look at how we are managing pregnancy," she says. "We have to zero-in on and improve how pregnant women are being educated." She adds that First Priority Health, like most payers, does not pay for home uterine monitoring of pregnancies.

Yet other prenatal programs find home monitoring to be a useful tool in preventing early delivery under special circumstances. "The monitor is sometimes a good idea for certain patients, primarily those on infusion pump tocolytic therapy. On average, we only recommend home monitoring in less than 10% of our high-risk maternity patients," says Robin Foust, director of programs and market development for Health Management Corporation (HMC), a disease management company in Richmond, VA.

"However, we have had overwhelming success with our education-based Baby Benefits prenatal program. In fact, in 1997, only 9% of our high-risk maternity cases delivered before 35 weeks; of all our 1997 maternity cases, only 5.3% delivered prior to 35 weeks."

HMC developed one of the nation's first telephonic and home-based perinatal nurse intervention programs and has managed more than 85,000 pregnancies since its implementation in 1989. Foust says some clients have a hard time detecting signs of preterm labor, and nurse intervention is valuable.

Of course, because HMC is a disease management company and not a payer, the company cannot approve expenditures for home monitoring, Foust points out. HMC perinatal nurses are patient advocates, however, and can make the recommendation for home monitoring if the case warrants it. Foust supports the findings of the article to an extent, but every case is different, and an individual management approach is the key to positive pregnancy outcomes, she explains.

Although Hack is not surprised by the study's findings in regard to monitoring, she says prenatal education is important for all pregnant women. "I think women in general should have in-depth education about pregnancy. To make a real impact, we need to start educating women way before they get pregnant."

References

1. Dyson DC, et al. Monitoring women at risk for preterm labor. N Engl J Med 1998; 338:15-19.

2. Iams J. Prevention of preterm birth. N Engl J Med 1998; 338:54-55.