Family members and friends who help beneficiaries make health decisions.

People enrolled in Medicare often turn to family members and friends for help in making health decisions, including Medicare health plan choices. To learn how family members and friends participate in decisionmaking, what information they currently use, and what information they would like, we held eight focus groups in San Diego and Baltimore. Although responses were different in the two markets, participants in both cities reported receiving inadequate information and indicated they were largely unaware of available CMS-supported information. Beneficiaries want easy-to-use print materials targeted to their needs and opportunities to participate in seminars and receive personal counseling.

The Door's Perinatal Program for Pregnant and Parenting Teens.

The perinatal program for urban youth at The Door, located in New York City, provides accessible, comprehensive, high-quality prenatal services to pregnant teens. Through a holistic, family-centered, youth-development approach, the program seeks to counteract the adverse medical risks and psychosocial consequences of early childbirth and child rearing in order to improve the immediate and long-term futures of the mother and her new family. The Door's services are presented, along with a description of the agency's service model and an analysis of 100 pregnant teens enrolled in its perinatal program.

A community-based approach to HIV case management: systematizing the unmanageable.

This article presents an analysis and typology of community-based care for a young Hispanic mother with acquired immune deficiency syndrome (AIDS). It develops a conceptual framework that examines retrospectively the needs generated by AIDS over time, the appropriateness of the services, and an assessment of the interventions. Community-based case management can effectively address some of the diverse and changing needs of AIDS patients and their families, such as bridging service gaps and fortifying patient and system strengths while minimizing their weaknesses. Community-based case managers may also be better equipped than hospital case managers to work with difficult patients and coordinate community- and hospital-based care. Conclusions are presented regarding the definition and implementation of community-based, culturally sensitive, family-centered human immunodeficiency virus case management, as well as the importance and difficulty of developing relationships among the family, health care providers, and institutions within the community.

Reproductive risks. Guatemala.

PIP: In Guatemala, where women exert little control over their reproductive lives, maternity is a risky undertaking. As a study a few years ago indicates, over 1/2 of all births are attended by untrained personnel. This situation is compounded by the health and socioeconomic conditions faced by Guatemalan women, who rarely receive the daily minimum caloric requirement. According to an epidemiological study in Guatemala City, 44% of pregnant women suffered from at least one parasite. These women were generally less educated, lived in worse sanitary conditions, and had a lower nutritional status than uninfected women. Between 1980-87, the overall maternal mortality rate in Guatemala was 110/100,000 live births, compared to a rate of 9/100,000 in the US. Many of these maternal deaths result from diseases and complications arising in the perinatal period, usually epileptic seizures, bleeding, premature labor, abortion, and postpartum infections. In addition to the women who die from pregnancy complications, many more are left permanently disabled. Complications such as infections and bleeding often result from illegal abortions, usually performed in unsanitary conditions by inexperienced individuals. Abortion rate estimates range from 4%-18% of all pregnancies. Guatemala bans abortion, except in a few life threatening conditions, when approval must be obtained from a committee and a physician. In reality, only women who can afford a private physician can secure approval for an abortion. While a 1985 WHO report argued that family planning is the first step in preventing illegal abortions and reducing maternal mortality, the growing anti-abortion movement in Guatemala has also begun to threaten support for family planning.^ieng

The community as a strategic site for refining high perinatal risk assessments and interventions.

This paper describes a community-based agency's approach to reducing perinatal risk among populations at high medical, familial and environmental risk. Following a descriptive analysis of 96 families enrolled in a maternal outreach program, a case study illustrates how client-sensitive strategies are applied to successfully engage a traumatized population. The intensity and duration of the interventions, the extensive outreach efforts to the family and the dedication and commitment of the staff are not easily replicated but invaluable in helping providers and researchers understand to what extent the impact of severe deprivations and risk can be mediated and potential damage to the newborn prevented. The paper concludes that community-based agencies in partnership with social and clinical researchers from a tertiary care setting provide the key for developing more effective, integrated perinatal care by virtue of the critical density of hard-to-reach patients who can be followed by providers and clinical researchers.