Contraceptive use among Medicaid-covered teens and risk of teen conception: a longitudinal study.

OBJECTIVE: To investigate Medicaid-covered teens' receipt of physician-prescribed contraceptives and the impact of this receipt on pregnancy rates before and after welfare reform and the expansion of children's public health insurance in the late 1990s. METHODS: Contraceptive prescriptions and pregnancy events were identified from Medicaid claims for two 24-month periods (January 1, 1994-December 31, 1995, and January 1, 2000-December 31, 2001). Participants were all female Medicaid beneficiaries aged 15-19 enrolled anytime in the two 24-month periods, excluding teens pregnant within the first 3 months of enrollment, with incomplete enrollment data or undocumented immigration status, enrolled in a capitated Medicaid plan, or with other concurrent health coverage. We used a discrete-time hazard model to examine the association between paid contraceptive prescriptions and other variables and conception in Florida and Georgia. RESULTS: Receipt of physician-prescribed contraceptives increased from 11% to 18% among Florida teens and from 22% to 27% among Georgia teens during the study period. Georgia teens receiving contraceptive prescriptions were 45% less likely to conceive than teens with no contraceptive prescriptions in 1994-1995 and 64% less likely in 2000-2001. In Florida, teens receiving contraceptive prescriptions were one third less likely to conceive than teens with no contraceptive prescriptions in both 1994-1995 and 2000-2001. CONCLUSIONS: An increase in the receipt of contraceptive prescriptions paid by Medicaid may help in reducing pregnancies among low-income teens.

The costs of public services for teenage mothers post-welfare reform: a ten-state study.

BACKGROUND: More information is needed on the use and costs of public services by teens after the passage of major national polices in the 1990s. Both the 1996 welfare reform and later changes to the Medicaid program have affected the access of low-income adolescents to public assistance programs. In turn, these changes have affected teenaged mothers and their infants and the costs that taxpayers incur in the 50 states. STUDY QUESTION: What public services do teenage mothers use and what are their costs in the decade after the major policy changes to public assistance programs? How do patterns vary by state? METHODS: This study examines the use by teenage mothers of four public services: cash assistance, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), food stamps, and Medicaid coverage at delivery. We used 2000 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to derive rates of use for these four programs in ten states-AK, AL, FL, ME, NY [excluding New York City], NC, OK, SC, WA, and WV. We combined the rates with data on per person and family costs of these four programs to present 'birth-year' costs for a cohort of teenage mothers in the ten states. To provide a baseline from which to measure incremental public service costs to teenage mothers, we also compiled the data for mothers ages 20 to 24 years who did not report births during their teen years. RESULTS: Data from the ten states indicate that the birth-year expenses for teenage mothers for four public programs add up to more than $0.5 billion, and the costs per teenage mother exceed those for older mothers who did not have a teenage birth by almost $1,500. The largest component of these public costs is Medicaid coverage at delivery at 87 percent of the total. If all of the unintended births to teenage mothers in the ten study states were postponed, $75 million in public sector costs would be averted annually. CONCLUSIONS: The use of public programs by teenage mothers remains costly and varies markedly across the ten study states. A key reason for higher costs among teenage mothers than among mothers in their early twenties is their higher rates of enrollment in Medicaid at delivery. This rate of enrollment also varies markedly across the study states. The high level of incremental costs and rate of unintended births to teens indicate that cost-saving interventions could be developed. PUBLIC HEALTH IMPLICATIONS: Data indicate that many teenage pregnancies are unintended. Thus, a clear public health goal should be to implement and evaluate programs aimed at reducing unintended pregnancies among teenagers. Initiatives are needed to help young women make well-informed decisions about sexual activity and other risky behaviors. Insurance coverage is important to all teens and especially to those who are sexually active.

Explaining racial differences in prenatal care initiation and syphilis screening among Medicaid-covered pregnant women.

Sexually transmitted diseases and their outcomes disproportionately affect non-Hispanic Blacks who also receive later prenatal care. We used a sample of low-income pregnant women insured by Medicaid to assess racial disparities in the receipt of first trimester prenatal care and any as well as early (by 2nd trimester) syphilis screening. We used an older but unique file of linked 1995 Georgia Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) births (n=1,096) to test the relative explanatory power of factors contained in administrative versus survey data. Using administrative data, we found non-Hispanic Blacks were less likely than non-Hispanic Whites to receive first trimester care but more likely to be screened. Adding in PRAMS survey data eliminated these differences. Having an outpatient department as usual source of care was a key factor. This may reflect unmeasured characteristics of minorities and their neighborhoods or differences in screening practices across provider settings.

The State Children's Health Insurance Program (SCHIP) and prepregnancy coverage of teenage mothers.

BACKGROUND: The 1997 State Children's Health Insurance Program (SCHIP) program allowed states to expand Medicaid to uninsured children through age 18 in families under 200% of the federal poverty level. Prepregnancy insurance coverage of adolescents may help reduce unintended pregnancies, address other medical issues, and allow for early and adequate prenatal care for those carrying to term. OBJECTIVES: We tested the effects of SCHIP implementation on insurance coverage for teenage mothers and investigated whether these effects varied by type of state SCHIP program--Medicaid expansion, stand-alone program, or some combination of these. RESEARCH DESIGN: We used Pregnancy Risk Assessment Monitoring System data from 1996 through 2000 and difference-in-differences analysis to analyze coverage changes for teenage mothers (age <20) relative to those for mothers aged 20-24 years old, a group whose Medicaid eligibility was not affected by SCHIP policies. POPULATION STUDIED: Our raw sample of teenage and older mothers in Alaska, Oklahoma, South Carolina, Florida, Maine, New York, and West Virginia equaled 23,171 (811,638 weighted). RESULTS: SCHIP implementation was associated with an almost 10 percentage point increase in prepregnancy coverage among teens under age 17. Although there were increases in both public and private coverage only the latter was statistically significant. The only statistically significant increase in Medicaid coverage, equal to almost 16 percentage points, was among 18-year-olds in states with Medicaid expansion programs. CONCLUSIONS: The temporary extension of SCHIP allows time to consider how to maintain the program's potentially positive effect on the reproductive health of adolescents.

Racial disparities in Medicaid enrollment and prenatal care initiation among pregnant teens in Florida: comparisons between 1995 and 2001.

BACKGROUND: Teens and racial and ethnic minority women are less likely to initiate prenatal care (PNC) in the first trimester of pregnancy than their counterparts. OBJECTIVE: This study examines the impact of Medicaid program changes in the late 1990s on the timing of Medicaid enrollment and PNC initiation among pregnant teens by race and ethnicity. RESEARCH DESIGN: Using Medicaid enrollment and claims data and a difference-in-differences method, we examine how the patterns of prepregnancy Medicaid enrollment, PNC initiation, and racial and ethnic disparities in PNC changed over time after controlling for person- and county-level characteristics. SUBJECTS: We included 14,089 teens in Florida with a Medicaid-covered delivery in fiscal years 1995 and 2001. MEASURES: Prepregnancy enrollment was defined as enrollment 9 or more months before delivery; late or no PNC was defined as initiation of PNC within 3 months of delivery or not at all. RESULTS: For teens enrolled in traditional welfare-related categories, the proportion with prepregnancy Medicaid enrollment increased and the proportion with late or no PNC declined from 1995 to 2001. Teens enrolled under the Omnibus Budget Reconciliation Act (OBRA) expansion category in 2001 were less likely than welfare-related teen enrollees to have prepregnancy coverage but were more likely to initiate PNC early. Racial disparities were found in PNC initiation among the 1995 welfare-related group and the 2001 expansion group but were eliminated or greatly reduced among the 2001 welfare-related group. CONCLUSIONS: Providing public insurance coverage improves access to care but is not sufficient to meet Healthy People 2010 goals or eliminate racial and ethnic disparities in PNC initiation.

Asthma-related medication use among children in the United States.

BACKGROUND: Asthma is one of the most common chronic conditions in children and has a major impact on health care use and quality of life. The Best Pharmaceuticals for Children Act mandates the federal government to sponsor pediatric studies of drugs approved for use in the United States but lacking evaluation in the pediatric population and lacking interest of commercial sponsors. As input into the drug selection and prioritization process, information is needed on the percentage of children who receive asthma-related medications. OBJECTIVE: To estimate the percentage of children who receive asthma-related medications. METHODS: Retrospective analysis of outpatient medical and drug claims from members of commercial health care insurance plans enrolled any time from January 1, 2004, through December 31, 2005. The study population included 4,259,103 children throughout the United States aged birth through 17 years. RESULTS: Fifteen percent of all children were dispensed an asthma-related medication. Among 218,943 children with an asthma diagnosis, 188,286 (86%) had a dispensed asthma-related medication at any time during the 2-year study period. Among children without any asthma diagnoses, 398,880 (10%) had a dispensed medication. Fifty-nine percent of children with an asthma diagnosis were dispensed an anti-inflammatory medication within 90 days after a claim with a diagnosis of asthma. CONCLUSIONS: Asthma-related medications are dispensed to a large percentage of the pediatric population, including many who do not have claims with asthma diagnoses listed. Data on the pharmacokinetics and safety of these drugs in children are largely unknown and difficult to obtain. Clinical studies that use new tools and approaches are needed to resolve this information gap.

Racial and ethnic disparities in prenatal syphilis screening among women with Medicaid-covered deliveries in Florida.

OBJECTIVES: Black and Hispanic infants are 19.9 and 10.3 times more likely, respectively, than white infants to develop congenital syphilis (CS), a disease that is preventable with timely prenatal screening and treatment. We examined racial/ethnic group differences in prenatal syphilis screening among pregnant women with equal financial access to prenatal care through Medicaid. METHODS: We used Florida claims data to examine any, early, and repeat screening among non-Hispanic white, non-Hispanic black, and Hispanic women with Medicaid-covered deliveries in FY1995 (n=56,088) and FY2000 (n=54,073). We estimated screening rates for each group, and used logistic regression to assess whether screening disparities remained after controlling for other factors, including Medicaid enrollment characteristics and prenatal care source, and associations between access-related factors and screening odds for each group. RESULTS: Between FY1995 and FY2000, rates of any and early syphilis screening increased, while repeat screening rates decreased. In FY1995, any, early, and repeat rates were highest for blacks and lowest for Hispanics. In FY2000, any and early screening rates were highest for whites and lowest for blacks, while repeat screening rates were similar across groups. Racial/ethnic differences in any and early screening remained for non-Hispanic blacks after adjustment. In general, Medicaid enrollment early in pregnancy, primary care case management participation, and use of a safety net clinic were associated with higher screening odds, though results varied by test type and across groups. CONCLUSIONS: Unexplained racial/ethnic disparities in prenatal syphilis screening remain for blacks, but not Hispanics. Individual, provider, and program factors contribute to differences across and within groups.

The impact of welfare reform on insurance coverage before pregnancy and the timing of prenatal care initiation.

OBJECTIVE: This study investigates the impact of welfare reform on insurance coverage before pregnancy and on first-trimester initiation of prenatal care (PNC) among pregnant women eligible for Medicaid under welfare-related eligibility criteria. DATA SOURCES: We used pooled data from the Pregnancy Risk Assessment Monitoring System for eight states (AL, FL, ME, NY, OK, SC, WA, and WV) from 1996 through 1999. STUDY DESIGN: We estimated a two-part logistic model of insurance coverage before pregnancy and first-trimester PNC initiation. The impact of welfare reform on insurance coverage before pregnancy was measured by marginal effects computed from coefficients of an interaction term for the postreform period and welfare-related eligibility and on PNC initiation by the same interaction term and the coefficients of insurance coverage adjusted for potential simultaneous equation bias. We compared the estimates from this model with results from simple logistic, ordinary least squares, and two-stage least squares models. PRINCIPAL FINDINGS: Welfare reform had a significant negative impact on Medicaid coverage before pregnancy among welfare-related Medicaid eligibles. This drop resulted in a small decline in their first-trimester PNC initiation. Enrollment in Medicaid before pregnancy was independent of the decision to initiate PNC, and estimates of the effect of a reduction in Medicaid coverage before pregnancy on PNC initiation were consistent over the single- and two-stage models. Effects of private coverage were mixed. Welfare reform had no impact on first-trimester PNC beyond that from reduced Medicaid coverage in the pooled regression but separate state-specific regressions suggest additional effects from time and income constraints induced by welfare reform may have occurred in some states. CONCLUSIONS: Welfare reform had significant adverse effects on insurance coverage and first-trimester PNC initiation among our nation's poorest women of childbearing age. Improved outreach and insurance options for these women are needed to meet national health goals.

Patterns in prenatal syphilis screening among Florida Medicaid enrollees.

OBJECTIVE: The objective of this study was to assess the rate of prenatal syphilis screening and compliance with clinical guidelines on the receipt of early and repeat screening in a Medicaid population before and after implementation of the National Plan to Eliminate Syphilis. STUDY DESIGN: Rates of office- and clinic-based prenatal syphilis screening among pregnant women with Medicaid-covered deliveries in Florida in fiscal years (FYs) 1995 and 2000 are analyzed using Medicaid claims data. RESULTS: The proportions of women receiving any, early, and repeat prenatal syphilis screening increased sharply between FY 1995 and FY 2000 but remain well below recommended levels. Screening is highly correlated with timing of prenatal care and Medicaid enrollment duration. CONCLUSIONS: Further efforts to improve screening rates will need to both increase the proportion of women who receive timely prenatal care and ensure that providers comply with guidelines to provide syphilis screening as a component of prenatal care for all women.

Health service use and outcomes among disabled Medicaid pregnant women.

PURPOSE: We investigated differences in health service use and pregnancy outcomes among women enrolled in Medicaid under eligibility categories for the blind and disabled and those enrolled under other eligibility categories. METHODS: We used Medicaid enrollment and claims data to create episodes of pregnancy- and delivery-related care for women with and without disabilities who had Medicaid-covered deliveries in Florida, Georgia, and New Jersey during 1995 and Texas during 1997. We linked birth certificate information on prenatal care and birth outcomes to the files for Georgia and Texas. We then computed the unadjusted and adjusted odds ratios for the receipt of selected routine prenatal and illness-related services and the occurrence of selected pregnancy outcomes among women with disabilities relative to women without disabilities. FINDINGS: In all states, women with disabilities were more likely than women without disabilities to have had continuous Medicaid coverage from preconception through the postnatal period. Women with disabilities were equally or less likely to have received adequate prenatal care compared to women without disabilities in the two study states with these data. They were also more likely to have had emergency room visits, hospital admissions during pregnancy, cesarean deliveries, and readmissions within 3 months of delivery in all study states. We also found women with disabilities to have been more likely to deliver preterm and low birthweight infants. CONCLUSION: Our results suggest that opportunities exist to improve access to prenatal care among women with disabilities enrolled in Medicaid under blind and disabled eligibility categories who become pregnant.

Perinatal depression: a systematic review of prevalence and incidence.

OBJECTIVE: We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at non-childbearing times. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. TABULATION, INTEGRATION, AND RESULTS: Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at non-childbearing times. CONCLUSION: To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.

Welfare reform, insurance coverage pre-pregnancy, and timely enrollment: an eight-state study.

Implementation of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) broke the automatic linkage between Medicaid eligibility/enrollment and welfare cash assistance for women eligible at welfare income levels. This study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for the period 1996-1999 to examine insurance coverage of these and other pregnant women pre- and post-PRWORA. Controlling for individual characteristics and economic growth, the relative odds of having private insurance did not change while the odds of being Medicaid enrolled versus uninsured pre-pregnancy declined for welfare-eligible women post-PRWORA. The absolute effect was a decline of 7.9 percentage points in the probability of welfare-eligible women being insured. While these results apply to the early years of welfare reform, it is still likely that states can improve Medicaid outreach and enrollment of women eligible prior to pregnancy.

Access for pregnant women on Medicaid: variation by race and ethnicity.

Disparities in early and adequate prenatal care and infant/maternal outcomes still exist between white and nonwhite populations. Although Medicaid expansions were intended to improve outcomes, eligible women often delay enrollment and access barriers remain. This study examines racial disparities among pregnant women in Florida, Georgia, New Jersey, and Texas. The disproportionate location of minorities enrolled in Medicaid in urban areas with greater physician supply was not found to increase office-based prenatal care among blacks. More local physicians, especially foreign medical graduates, sometimes increased access, largely for Hispanics. The presence and use of safety net providers did increase prenatal care use among minorities. This evidence lends support to policies to maintain safety net providers, which are perhaps better equipped than others to serve low-income populations. However, policies should encourage participation extending to all racial/ethnic groups by office-based physicians. The role of foreign medical graduates, who are more likely to participate in Medicaid, should be considered.

Medicaid service use and program costs for pregnant teens.

Teen pregnancy is an important public health issue for all teens, but particularly for low-income teens who rely on the public health safety net for services. Medicaid pays for more than two-thirds of deliveries among teenagers in the USA. To discern how this public program serves pregnant teens (aged 11-19 years), the authors used Medicaid enrollment and claims data for Florida, Georgia and New Jersey in 1995 to examine teens' enrollment duration, service use and average payments relative to 20-24-year-olds on Medicaid. Teens were more likely than the older women to have been enrolled in Medicaid before pregnancy and to have maintained coverage through the third month following delivery. If not enrolled prepregnancy, teens were more likely than older women to enroll later in pregnancy. Teens were less likely to receive early prenatal care and more likely to be hospitalized during pregnancy, usually for preterm labor. While total Medicaid payments for routine prenatal and delivery-related care were equivalent between teens and older women, payments for nonroutine care during pregnancy were modestly higher for teens in Florida and Georgia. Thus, only modest cost savings can accrue from lower average costs per pregnancy and delivery among teens who delay pregnancy. Additional and larger cost savings to the Medicaid program from preventing teen pregnancy would accrue from the expected lower enrollment in Medicaid among the teens as they age.

Racial and ethnic disparities in the use of pregnancy-related health care among Medicaid pregnant women.

OBJECTIVE: To assess the extent to which racial and ethnic disparities exist in the use of prenatal services among Medicaid pregnant women. METHODS: Medicaid claims data for Florida, Georgia, New Jersey, and Texas, with linked birth certificate data for Georgia and Texas, were used to investigate the use of selected prenatal services, including the initiation and adequacy of prenatal care visits; prescriptions for multiple vitamins and iron supplements; and claims for complete blood cell counts, blood type and RH status, hepatitis B surface antigen, ultrasound, maternal serum alphafetoprotein, drug screening, and HIV tests. We computed raw and adjusted odds ratios of having the health service of interest during pregnancy for women in three minority groups: black non-Hispanics, Hispanics, and Asian/Pacific Islanders. RESULTS: We found racial and ethnic disparities in the use of every health service investigated. Compared with white non-Hispanics, minority women were less likely to receive services that the woman initiates, discretionary services, and services potentially requiring specialized follow-up care, whereas they were more likely to receive screening tests for diseases related to high-risk behaviors. Disparities were generally larger, more consistent across states, and less likely to be explained by other factors among black non-Hispanics than among either Hispanics or Asian/Pacific Islanders. CONCLUSIONS: Even among women who are provided equal financial access to health care services, unexplained racial and ethnic disparities persist in the initiation and use of both routine and specialized prenatal care services.

Medical care costs associated with postmenopausal estrogen plus progestogen therapy.

OBJECTIVE: To investigate the medical management costs of estrogen plus progestogen hormone therapy (HT) among postmenopausal women taking HT primarily as a preventive treatment for osteoporosis. DESIGN: Retrospective longitudinal comparative analysis of HT users and demographically matched nonusers using administrative databases on physician services, hospital stays and prescription medications. SETTING: Saskatchewan, Canada. PATIENTS: a total of 5762 women aged 55 years or more who took HT sometime between 1990 and 1997 and 5762 demographically matched controls who did not take HT from 1990 to 1997. MAIN OUTCOME MEASURES: total medical care expenditures and apparent costs of managing adverse events associated with HT. RESULTS: Excluding drug acquisition costs for HT and costs of care for osteoporosis, women in their first year of postmenopausal HT had total medical care costs about $400 greater than women who had never used HT (1997 Canadian dollars). This total medical care cost differential falls to about $90 to $120 per annum after the first year of therapy. If osteoporosis-related medical care costs are not excluded, the cost differential is about $390 during the first year of therapy and $80 to $110 per annum after the first year of therapy. These excess costs primarily are the result of excess rates of resource utilization for uterine- and breast-related diagnostic and treatment procedures. CONCLUSION: Medical management costs for HT may be substantial during the first year of therapy, and some medical management costs may persist over several years. These short-term management costs, combined with recent data about the long-term safety of HT as a preventive therapy, reinforce the importance of considering therapeutic alternatives to HT.

Tocolytic treatment for the management of preterm labor: a review of the evidence.

OBJECTIVE: Preterm labor is often a prelude to early births and the significant attendant burden of infant morbidity and mortality. Treatment consists of bedrest, hydration, pharmacologic interventions, and combinations of these. We systematically reviewed the effectiveness of tocolytics to stop uterine contractions (first-line therapy) or maintain quiescence (maintenance therapy). Our objective was to evaluate the evidence on the benefits and harms of five classes of tocolytic therapy for treating uterine contractions related to preterm labor--beta-mimetics, calcium channel blockers, magnesium, nonsteroidal anti-inflammatory agents, and ethanol. STUDY DESIGN: Reports of randomized controlled trials and other study designs in English, French, and German identified from searches of MEDLINE, EMBASE, specialized databases, bibliographies of review articles, unpublished literature, and discussions with investigators in the field were identified. Studies on women with preterm labor between 1966 and February 1999 that met our inclusion criteria were included. Through dual review, we abstracted the following information: study design and masking; definitions of preterm labor and successful tocolysis; patient inclusion/exclusion characteristics; patient demographic characteristics; drug and cointerventions; and numerous birth, maternal, and neonatal outcome measures. RESULTS: Of the 256 articles evaluated, we abstracted data from 60 first-line and 15 maintenance studies. Of these, 16 first-line and 8 maintenance studies met more stringent requirements for meta-analyses. Studies of first-line tocolysis (grade Fair) reveal a mixed outcome pattern with small improvement in pregnancy prolongation and birth at term relative to placebo. Data were insufficient to show directly a beneficial effect on neonatal morbidity or mortality. Ethanol was less beneficial than, and beta-mimetics were not superior to, other tocolytic options. Maintenance tocolytics (grade Poor) showed no improvements in birth or infant outcomes relative to placebo; these results were confirmed through meta-analysis. In contrast to other tocolytic treatments, maternal harms from beta-mimetics were rated High; all tocolytics were rated as Low risk for short-term neonatal harms. CONCLUSIONS: Management of uterine contractions with first-line tocolytic therapy can prolong gestation. Among the tocolytics, however, beta-mimetics appear not to be better than other drugs and pose significant potential harms for mothers; ethanol remains an inappropriate therapy. Continued maintenance tocolytic therapy has little or no value.

Transitions in insurance coverage from before pregnancy through delivery in nine states, 1996-1999.

Efforts to extend coverage to pregnant women, along with an expanding economy, did not prevent increases in the uninsured in the latter 1990s. Welfare reform may have led to declining Medicaid enrollments and caseloads. Data representative of live births in nine states show that in some states more than one-third of all pregnant women and almost two-thirds of low-income pregnant women lacked insurance before their pregnancy in 1996 and 1999. More than one-third of all pregnant women made some change in coverage by the time they delivered their baby. Among low-income women, the largest change was from uninsured status before pregnancy to Medicaid at delivery.

Antibiotic therapy for the treatment of preterm labor: a review of the evidence.

OBJECTIVE: The purpose of this study was to evaluate the evidence regarding antibiotics for the treatment of preterm labor. STUDY DESIGN: Through dual review, we abstracted study design and masking, definitions of preterm labor and pregnancy outcome, patient inclusion/exclusion characteristics, patient demographic characteristics, drug and cointerventions, and numerous birth, maternal, and neonatal outcome measures. We graded the quality of the individual articles and the strength of the evidence for antibiotic benefit. RESULTS: We abstracted data from 14 randomized trials and 1 observational study. Of these studies, 13 trials met the requirements for a meta-analysis. The meta-analysis demonstrated a mixed outcome pattern with small improvements in pregnancy prolongation, estimated gestational age at birth, and birth weight. Data were insufficient to show a beneficial effect on neonatal morbidity or mortality rates. CONCLUSION: Treatment of preterm labor with antibiotic therapy can prolong gestation. The benefits of antibiotics are small, and there is considerable uncertainty about the optimal agent, route, dosage, and duration of therapy.

Children's Use of Primary and Preventive Care Under Medicaid Managed Care.

The authors found that two mandatory Medicaid primary care case management (PCCM) programs were somewhat successful in improving access to primary care among children in the early 1990s. However, the Florida program, in which the PCCM benefit package included Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, did not meaningfully increase EPSDT screening visits among preschoolers. Further, the increase seen in New Mexico, where EPSDT was carved out of the PCCM benefit package, was evident for both program participants and non-participants and therefore could not be attributed to the PCCM program.