AB 1278 And The Month
Prenatal Care Began
Introduction
California
Assembly Bill No. 1278, as introduced by Assembly Member Emmerson, is a legislative
act that would amend sections of the state’s Health and Safety Code related to
vital records. Specifically, AB 1278
would change a number of confidential data items on the Certificate of Live
Birth, as specified in Sections 102430 and 102447. Among these items is
information related to the mother’s prenatal care, a historically important
indicator of maternal and infant health.
Current statute specifies that the month prenatal care began and the
number of prenatal visits be collected.
AB 1278,
however, strikes out the month prenatal care began and substitutes the date of
first prenatal visit and the date of last prenatal visit. This is because the bill intends to make
California’s birth certificate consistent with the US Standard Certificate of
Live Birth, which no longer contains the month prenatal care began. The
rationale for the change is based on the assumption that the month prenatal
care began can be computed from date of last normal menses, which will remain
on the birth certificate, and the date of first prenatal visit. While this is computationally possible, it is
likely that the number of unknown values for the month prenatal care began will
increase by several-fold if this indirect method is used, as compared to the
current method of collecting the data item by direct means.
There are
two principal reasons why the indirect method of collecting month prenatal care
began would have more unknown values than would the direct method:
1. The date of last normal menses is incompletely
reported and often in error.
2. It is likely that the date of first prenatal
visit will also be incompletely reported, especially since it will be collected
for the first time in California.
The
proportion of unknowns for month prenatal care began using the direct method is
currently about 1.5 percent. For the
date of last normal menses, the number of unknowns is about four times higher
at nearly 6 percent. Since it is not on
the current California birth certificate, the proportion of unknowns for date
of first prenatal visit can only be estimated, but other states that have
already began collecting this data item have reported rates for unknowns
ranging from 6.5 percent to over 17 percent.
It is therefore likely that if month prenatal care began is deleted from
the California Certificate of Live Birth the proportion of unknown month
prenatal care began (as ascertained indirectly) will increase at least by
four-fold and conceivably by ten-fold.
Ideally,
therefore, California would continue to collect the month prenatal care began
by both the direct and by the indirect method until such a time that the
quality of data using the indirect method can meet traditional standards. The time it takes for this to occur could
conceivably be shortened by two complementary means:
1. Utilize current electronic birth registration
technology to improve prenatal care reporting.
2. Educate hospital staff regarding the optimal
methods for reporting prenatal care.
With
respect to the first means, California’s electronic birth registration system,
the Automated Vital Statistics System (AVSS), has for more than two decades
been capable of using the date of first prenatal visit to compute the month
prenatal care began. For example, the
AVSS context-specific help text for the month prenatal care began (Item 25B on
the birth certificate) prompt is as follows:
ENTER THE
NUMBER OF THE MONTH OF PREGNANCY THAT PRENATAL CARE BEGAN,
THAT IS,
WHEN THE MOTHER FIRST VISITED A DOCTOR OR HEALTH PROVIDER
FOR MEDICAL
SUPERVISION OF THIS PREGNANCY.
FOR EXAMPLE,
'1ST', '2ND', '3RD', ... UP TO '9TH'.
ALTERNATIVELY,
YOU MAY LET AVSS
COMPUTE THE BEGINNING MONTH BY ENTERING
THE DATE WHEN PRENATAL CARE BEGAN (MM/DD/YY)
OR (MM/YY),
ENTER '0' IF
THERE WAS NO PRENATAL CARE,
OR 'UNK' IF THERE IS ABSOLUTELY NO
INFORMATION ON PRENATAL CARE,
OR ^L FOR A LIST OF VALID RESPONSES.
With
respect to the second means, California’s Office of Vital Records (OVR) has
recently began conducting regional workshops throughout the state for local
health department and hospital staff with the objective of improving the
quality of vital records data.
Therefore,
it is conceivable that OVR workshops can motivate hospital staff to more
frequently use AVSS to compute the month prenatal care began by entering the
date of first prenatal visit. If this
effort is successful then it could conceivably reduce the number of unknowns
for the date of first prenatal visit when it is placed on the California
Certificate of Live Birth.
Methods
Recognizing
the importance improving the reporting date of first prenatal visit, AVSS
Project staff developed an auditing mechanism to monitor its use by hospital
staff when reporting the month prenatal care began. This recognition was stimulated by the
language contained in AB 1278, as described above. The auditing tool was placed into production
on May 24, 2005 using AVSS/NET, the Internet version of AVSS, which now
accounts for more than 90 percent of California’s births.
On June 2,
2005 OVR staff conducted a regional vital records workshop in Oakland,
California with nineteen AVSS/NET hospitals from five local health departments
in attendance. During this workshop, OVR
specialists educated hospital staff regarding existing AVSS capability for
using the date of first prenatal visit to compute the month prenatal care
began. Instructions on using this
capability were also posted
on the AVSS website.
A
pre-workshop time period was defined as from May 24 to June 1, 2005. And a
post-workshop time period was defined as from June 3 to June 9, 2005.
Results
The
pre/post change in the use of the date of first prenatal visit to compute the
month prenatal care began is reported by hospital and local health department
in Table 1.
Table 1. Change in the use of date
of first prenatal visit to compute the month prenatal care began in AVSS/
|
Hospital/County |
Pre (%) |
Post (%) |
Change (%) |
|
Hospital_A01 |
0.0 |
2.3 |
2.3 |
|
Hospital_B01 |
9.1 |
51.5 |
42.4 |
|
Hospital_C01 |
0.9 |
1.5 |
0.6 |
|
Hospital_D01 |
0.0 |
2.9 |
2.9 |
|
Hospital_E01 |
0.0 |
5.9 |
5.9 |
|
Hospital_F01 |
0.0 |
1.0 |
1.0 |
|
County_01 |
1.8 |
11.9 |
10.1 |
|
|
|
|
|
|
Hospital_A38 |
14.3 |
25.0 |
10.7 |
|
County_38 |
14.3 |
25.0 |
10.7 |
|
|
|
|
|
|
Hospital_A41 |
3.1 |
64.7 |
61.6 |
|
County_41 |
3.1 |
64.7 |
61.6 |
|
|
|
|
|
|
Hospital_A43 |
0.0 |
0.0 |
0.0 |
|
Hospital_B43 |
0.0 |
0.0 |
0.0 |
|
Hospital_C43 |
0.0 |
0.0 |
0.0 |
|
Hospital_D43 |
0.0 |
0.0 |
0.0 |
|
Hospital_E43 |
0.0 |
31.9 |
31.9 |
|
Hospital_F43 |
0.0 |
1.4 |
1.4 |
|
Hospital_G43 |
0.0 |
0.0 |
0.0 |
|
County_43 |
0.0 |
5.1 |
5.1 |
|
|
|
|
|
|
Hospital_A48 |
36.8 |
100.0 |
63.2 |
|
Hospital_B48 |
55.9 |
83.9 |
28.0 |
|
Hospital_C48 |
0.0 |
19.0 |
19.0 |
|
Hospital_D48 |
25.9 |
62.1 |
36.2 |
|
County_48 |
26.4 |
57.3 |
30.9 |
|
|
|
|
|
|
Total |
0.4 |
13.2 |
12.8 |
The
aggregate results are encouraging with the use of date of first prenatal visit
rising from practically zero to 13.2 percent.
Changes for some hospitals were even more dramatic with one hospital
using date of first prenatal visit 100 percent of the time in the post period. The degree of improvement appears to be local
health department-specific, with the percent using date of first visit in the
post period varying from 5.1 percent to 57.3 percent. This variation appears to be the result of
individual hospitals having used the AVSS capability before the OVR workshop
was conducted. That is, the hospitals
that showed the greatest improvement generally were already acquainted with the
ability of AVSS to accept the date of first prenatal visit to compute the month
prenatal care began.
The degree
of improvement also varied within each hospital by user. For example, in the hospital that showed the
greatest improvement (Hospital_A41 in County_41), User A in Table 2 attended
the workshop and began using date of first visit 100.0% of the time following
the workshop. User B, who did not attend the workshop, also used date of first
visit 100% in the post period. Another
non-workshop attendee --- User C, however, showed no change and did not use
date of first visit at all. It is possible therefore that User A communicated
the workshop instructions to User B, but not to User C.
Table 2. Change in the use of date
of first prenatal visit to compute the month prenatal care by AVSS/NET users in
Hospital_A41.
|
User |
Pre (%) |
Post (%) |
Change (%) |
|
A (Workshop) |
0.0 |
100.0 |
100.0 |
|
B |
0.0 |
100.0 |
100.0
|
|
C |
0.0 |
0.0 |
0.0 |
|
Total |
0.0 |
64.7 |
64.7 |
Other
hospitals also showed large variations in the use of date of first visit by
user. In general, those AVSS users who
attended the workshop showed a much higher usage of the date of first visit in
the post period than those who did not attend the workshop. For example, in County_48, which experienced
the second-largest improvement, users who attended the workshop used date of
first visit for 53.8 percent of births in the post period compared to only 23.1
percent for those who did not attend the workshop.
Although
the overall results are promising, five of the nineteen hospitals showed no change. All five of these hospitals were located in a
single county, thus suggesting that the local health department should perform
additional educational outreach.
Discussion
Statistics reporting
the month prenatal care began, as derived from the Certificate of Live Birth,
have been among California’s most important public health indicators for
several decades. These statistics are
widely used by state and local health agencies to monitor and improve maternal
and infant health. In so doing, it is
important that there be continuity in the definition and method of collection
for this variable. It is also essential
that the number of unknown values be kept to a minimum. This is especially true since high risk
subpopulations are most susceptible to unknown reporting. As it is currently written, AB 1278 would
risk increasing the number of unknowns for month prenatal care began and would
also create a historical discontinuity in the manner in which this variable is
defined and collected. Given the
importance of this public health indicator, that would be an unacceptable
outcome from legislation that is intended to improve the quality of
California’s vital records.
It is for
this reason that the AVSS Project does not endorse the deletion of the month
prenatal care began from the birth certificate.
However, as we have recognized for decades, using the date of first
prenatal visit is a useful adjunct in the reporting of month prenatal care began,
and it has potential for improving the accuracy of the measure. Yet, due to limited resources, the
availability of this AVSS capability has not been systematically communicated
to hospitals. However, as shown in the
results presented here, educational efforts in the use of AVSS capabilities by
the Office of Vital Records can greatly improve the use of date of first visit
by hospital staff. While the level of
improvement was impressive, it was not universal, thus indicating that it will
take some time for hospital staff to adjust to new reporting methods. We found that the hospitals most likely to
respond to OVR training in the use of AVSS capabilities were the ones that were
already somewhat familiar with them. We
therefore recommend that both variables be placed on the revised Certificate of
Live Birth for at least one year so as to allow sufficient time for hospital
staff to adjust to new reporting methods and to evaluate progress.
RLW:
6/14/05
