Foster D C, Guzick D S, Pulliam R P
Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD.
Obstet Gynecol. 1992 Jan;79(1):40-5.
A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.
西弗吉尼亚州南部一个由产科诊所开展的三县项目，旨在为未参保患者群体提供产前护理。1984年1月至1986年12月期间，在诊所项目接受产前护理的4534名患者中有1331名（29.4%）在二级医院分娩。在诊所运营期间，全院胎儿死亡率从每1000例活产11.8例降至7.2例，有统计学显著下降（P = .02）。在该项目期间，未参保患者的胎儿死亡率有统计学显著下降，从每1000例活产35.4例降至7.0例（P = .02），而那些有医疗救助覆盖的患者则没有下降。有私人保险的患者也有显著下降，从每1000例活产10.0例降至3.1例（P小于.001）。主要由于医疗事故保险费上涨导致运营费用不断增加，该项目于1986年12月暂停。1987年胎儿死亡率回升至每1000例活产10.3例死亡。在“诊所”阶段有显著变化的因素包括：剖宫产率、确诊的孕产妇高血压和糖尿病发生率较高；胎膜早破率和非白人人口比例较低。其他因素，包括35岁以上年龄、过期妊娠、双胞胎发生率、致命先天性异常发生率和单身婚姻状况，在诊所项目之前、期间或之后均无显著变化。本研究确定了一群不符合医疗救助覆盖资格且实际上“未参保”的高危患者。结果表明，为这群未参保的高危患者提供产前护理可降低胎儿死亡率。
