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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Prenatal - First Trimester Care Access

The goals of this module are to provide a detailed overview of the Prenatal - First Trimester Care Access clinical quality measure, outline the intended use for this measure, and highlight the benefits of implementing this measure into an organization's quality improvement (QI) program. The following is an overview of each section's content in this module:

Measure Description 

NameDescriptionNumeratorDenominatorSourceReference
Prenatal - First Trimester Care AccessPercentage of pregnant women beginning prenatal care in the first trimester of pregnancyNumber of pregnant women from the denominator who began prenatal care during the first trimesterTotal number of pregnant women who entered prenatal care during the measurement yearHEDIS
NCQA
HEDIS 2008 Summary Table of Measures, Product Lines and Changes Exit Disclaimer. [PDF | 71KB]

Part 1: Introduction

Part 2: Characteristics for Success: Prenatal - First Trimester Care

Part 3: Implementation of Clinical Quality Measure: Prenatal - First Trimester Care Access

Part 4: Improvement Strategies: Prenatal - First Trimester Care Access

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information


Part 1: Introduction 

There are over four million births per year in the United States and nearly one third of them will have some kind of pregnancy-related complication. Almost three women die every day from pregnancy complications in the United States, according to the Association of Maternal and Child Health Programs. Exit Disclaimer. Pregnant women, who do not receive adequate prenatal care, run the risk that complications will go undetected or may not be managed in a timely manner, which increases the possibility of adverse outcomes for the mother and baby. (1)

A number of peer-reviewed studies reiterate that early and regular prenatal care is an accepted strategy to improve health outcomes of pregnancy for mothers and infants. (2 - 16) Two of the most significant benefits of early and ongoing prenatal care are improved birth weight and decreased risk of preterm delivery. The average cost of medical care for a premature or low birth-weight baby for its first year of life is about $49,000, according to a new report from the March of Dimes Foundation. (17) By contrast, a newborn without complications costs $4,551 for care in its first year of life. (18,19) Infants born to mothers who received no prenatal care have an infant mortality rate five times that of mothers who received appropriate prenatal care in the first trimester of pregnancy. (19)

These are compelling reasons to ensure that prenatal care delivery is timely and of high quality. It is important to document the performance of our health care system in providing timely and high quality prenatal care. It is also imperative to improve performance to optimize the health outcomes of pregnancy for mothers and infants as needed.

Performance Measurement: Prenatal - First Trimester Care Access

It is well accepted that measuring performance allows an organization to document how well care is currently provided and lay the foundation for improvement. 

The Prenatal - First Trimester Care Access clinical quality measure is designed to measure enrollment of pregnant patients in the first trimester (i.e., first three months) and is an accepted way to assess the access to care for pregnant women. Enrollment in care during the first trimester of pregnancy is a reflection of timely initiation of prenatal care. Since early prenatal care is associated with positive pregnancy outcomes, increasing performance on this measure will contribute to positive health outcomes for mothers and babies. (20)

Consider the characteristics of a good performance measure and the IOM framework, Envisioning the National Healthcare Quality Report: Exit Disclaimer.

  • Relevance: Does the performance measure relate to a frequently-occurring condition or have a great impact on patients at an organization's facility?
  • Measurability: Can the performance measure realistically and efficiently be quantified given the facility's finite resources?
  • Accuracy: Is the performance measure based on accepted guidelines or developed through formal group decision-making methods?
  • Feasibility: Can the performance rate associated with the performance measure realistically be improved given the limitations of the clinical services and patient population?

To ensure that a performance measure has these characteristics, it is often based on, or aligned with, an organization's existing and proven measures.

The Prenatal - First Trimester Care Access measure aligns with measures endorsed by the National Committee for Quality Assurance (NCQA) and similar performance metrics used by HRSA grantees and programs. The measure also aligns with those adapted by the Office of Regional Operations (ORO) and is similar to the one used by the Bureau of Primary Health Care (BPHC) in the clinical portion of its Uniform Data Systems (UDS) process. Similar measures also exist in the national measure set for Healthy People 2020.

Clinical Measure: Prenatal - First Trimester Care Access

Measure Description 

NameDescriptionNumeratorDenominatorSourceReference
Prenatal - First Trimester Care AccessPercentage of pregnant women beginning prenatal care in the first trimester of pregnancyNumber of pregnant women from the denominator who began prenatal care during the first trimesterTotal number of pregnant women who entered prenatal care during the measurement yearHEDIS
NCQA
HEDIS 2008 Summary Table of Measures, Product Lines and Changes Exit Disclaimer. [PDF | 71KB]

As with all performance measures, there are essential inclusions, exclusions, and clarifications that are required to ensure that an organization collects and reports data in the same way. This allows an organization using the measure to compare itself with others. Detailed specifications for the measure, with descriptions of inclusion and exclusion criteria, are found in the section, Part 3: Data Infrastructure: Prenatal - First Trimester Care Access.

Improvement Experience: Prenatal - First Trimester Care Access

The Prenatal - First Trimester Care Access measure was chosen to align with existing measures. The data demonstrating the experience with these measures is discussed briefly in this section.

Early entry into prenatal care has been monitored on a national level since 1998 and continues to be a target for improvement as a Healthy People 2020 goal. Although prenatal care use improved significantly in recent years, especially among non-Hispanic Black, Hispanic, and American Indian/Alaska Native women, significant disparities continue to exist. In 2005, non-Hispanic White women had an 88.7 percent rate of early prenatal care, but no group achieved the Healthy People 2010 goal of 90 percent. Rates defined by race and ethnicity are illustrated in the following graph: (21)

Figure 1.1: Mothers Beginning Early Prenatal Care, by Race/Ethnicity

Figure 1.1: Mothers Beginning Early Prenatal Care, by Race/Ethnicity.

In the Medicaid population, NCQA measured timeliness of prenatal care and reported improvements from 76.5 percent first-trimester entry into care in 2003 to 81.4 percent in 2007. Ten percent of those reported were able to achieve rates at or exceeding 91.4 percent. (22)

This experience emphasizes that, while there is work left to do, improvement in first trimester prenatal care access is possible. Information highlighting characteristics of organizations that achieved success to improve first trimester prenatal care access is provided in Part 2: Characteristics for Success.




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