There is a growing awareness among public and private sector employers in the United States that healthy birth outcomes, productivity and the organization’s economic status are connected. Concurrently, there is heightened concern about occupational reproductive health hazards. Never before have employers had better reasons to improve maternal and infant health among employees and their families. Rising health care costs, changing workforce demographics, and increasing evidence that healthy employees lead to productivity gains, are compelling reasons to make maternal and infant health an addition to their health education and promotion programs.
A maternal and infant health strategy is a term broadly used to define any thoughtfully planned employer-sponsored or union-sponsored initiative that promotes the health and well-being of women, before, during, and after pregnancy, and supports the health of infants during the first year of life as well. There is no single solution or approach to improving maternal and infant health. Rather, for most employers, the effort is a combination of the following activities, custom-fit to meet the environment that makes their workplace unique.
Health Care Benefits
It is helpful to view maternal and infant health care benefits as a continuum of care that provides reproductive health awareness and family planning counseling and services throughout the reproductive life span. The benefits listed in table 1 represent those a health insurance plan should cover because of their significance in improving maternal and infant health.
Table 1. Health insurance benefits.
|
Pre-pregnancy |
Pregnancy |
Post-pregnancy |
Infancy |
|
Annual preconception or interconception care visit (includes family planning services) Genetic counseling and testing Prescription drug plan Substance abuse treatment |
Genetic counseling and testing Prenatal care–should be offered with no deductibles or copayments Labor and delivery at a hospital or birthing centre should be offered with no deductibles or copayments
|
Postpartum care Prescription drug plan Home health care services Substance abuse treatment |
Normal newborn nursery care Neonatal intensive care–no pre-existing conditions exclusions for newborns Prescription drug plan Home health care services |
Source: March of Dimes Birth Defects Foundation 1994.
Benefits design
While many American health care plans provide coverage for preconception and prenatal care, there are a number of reasons why it may be difficult for some women to obtain high quality, affordable care. For example, some providers require payment in advance for prenatal care and delivery services, yet most insurers will not make payment until after delivery. Other barriers to accessing proper care include high deductible fees or copayments, inconvenient office hours, lack of coverage for dependants, and geographic inaccessibility. Employers cannot eliminate all of these barriers, but it would represent an excellent beginning to help remove the burdens of upfront payments and high deductible fees and to offer assistance to the employee in finding acceptance by a suitable provider of prenatal care.
At Texas Instruments (TI), the goal is to make prenatal care affordable regardless of an employee’s income level or health care provider. Mothers seeking prenatal care inside the TI network pay only 10% of an upfront negotiated fee, a single charge that covers prenatal care services and both uncomplicated deliveries and Caesarean sections.
The Haggar Apparel Company pays 100% of the cost of prenatal care upfront if an employee or dependant accesses prenatal care in the first trimester of pregnancy. The Home Depot (a retailer of builder’s wares and related merchandise) waives the expectant mother’s hospital deductible fee if prenatal care visits begin in the first trimester.
While many plans provide for adequate care for a newborn’s first few days of life, coverage for the infant’s ongoing preventive care after leaving the hospital, frequently referred to as well-baby care, is often inadequate or nonexistent.
At the First National Bank of Chicago, expectant mothers who are enrolled in the indemnity plan and who complete a prenatal education program by the end of their fourth month of pregnancy have the $400 deductible charge waived from their newborn’s first year health insurance coverage. The Monfort Company, a beef packing plant in Greeley, Colorado, totally covers well-baby care up to age three.
Benefits-related Services and Employee Programs
Table 2 lists benefits-related services and programs that are considered important supportive features to a maternal and infant health strategy. These services and programs may be provided directly by the employer, either in the workplace or a nearby location, or under a contract with an outside agency or vendor, depending on the structure, location and size of the organization and may be administered by the benefits, employee health, health promotion or employee assistance department, for example.
Few companies can offer all of these components; however, the more complete and comprehensive the strategy, the better the chance of improving the health of mothers and babies.
Table 2. Other benefits-related services provided by the employer.
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SERVICES |
|||
|
Pre-pregnancy |
Pregnancy |
Post-pregnancy |
Infancy |
|
|
||
|
PROGRAMMES |
|||
|
Pre-pregnancy |
Pregnancy |
Post-pregnancy |
Infancy |
|
|
|
|
Source: March of Dimes Birth Defects Foundation 1994.
Pre-pregnancy and pregnancy period
Maternity management programs are gaining popularity because they offer attractive features to both the expectant parents and the employer. While not designed to replace prenatal care delivered by a health care professional, maternity management is a benefit-related service that provides personalized advice and support customized to a mother’s needs and risk levels.
Levi Strauss & Company, one of the nation’s largest clothing and apparel producers, offers a maternity management program administered by an insurance company. Employees are encouraged to access the program as soon as they are pregnant and they will receive $100 cash for calling the toll-free maternity management number. In 1992, costs for newborns whose mothers participated in the program were nearly 50% lower than for those whose mothers who did not.
The First National Bank of Chicago offers the March of Dimes Babies and You prenatal health promotion program as part of its maternal and infant health strategy. This program is described below and in the case study on p. 15.23 above.
Babies and You: A prenatal health promotion program
The March of Dimes’ Babies and You prenatal health promotion program was developed in 1982 in partnership with maternal and infant health care specialists throughout the country. Extensively field-tested by March of Dimes chapters and worksites, the program is continuously updated and enhanced.
Babies and You educates adults about how to practice healthy lifestyle behaviors before and during pregnancy, motivates women to get early and regular prenatal care, and influences employers to implement strategies that support healthy pregnancy outcomes.
Prenatal health promotion activities should be reaching male as well as female employees, partners, other family members and friends. Babies and You is adaptable to the unique needs of any given workforce. Consideration is given to the educational level, culture and language of prospective participants, as well as to any worksite restrictions and available community resources.
Because employers are at different stages in their health promotion activities, Babies and You offers three levels of implementation: an information campaign, educational seminars, and training of health professionals (see box). The most popular topics for informational materials and educational seminars are preconception and prenatal care, fetal development, genetics, the male role in pregnancy, nutrition during pregnancy, and parenting. The topics covered in the prenatal programs of 31 companies surveyed by the New York Business Group on Health found the dominant themes to be understanding what goes on during pregnancy and delivery; timely care by qualified health professionals; practicing healthy behaviors related to pregnancy and avoidance of hazards that might affect mother and/or fetus; care of the newborn; and maintaining satisfactory family and work relationships (Duncan, Barr and Warshaw 1992).
BABIES AND YOU: Levels of Implementation
Level I Informational Campaign is designed to create awareness at the worksite about the importance of early and regular prenatal care. To sustain this level of implementation, a variety of print and audiovisual materials is available from the March of Dimes.
Level II Educational Seminars are delivered at the worksite by March of Dimes volunteer health professionals. Fourteen different seminar topics are available to choose from, including: preconception care, prenatal care, nutrition, exercise and pregnancy, pregnancy after 35, stress and pregnancy, pregnancy complications, well-baby care, male role in pregnancy, and breastfeeding.
Level III Training of Health Professionals allows a worksite to establish Babies and You as an on-going component of its wellness activities. The March of Dimes provides a one-day training on program delivery and implementation to on-site health professionals such as occupational health nurses, benefits managers, medical directors and health promotion specialists.
But no matter what level of Babies and You a worksite chooses to implement, there are eight goals of a successful prenatal health promotion effort that this program strives to achieve:
- Management commitment
- Inter-departmental program planning
- Employee input
- The offering of incentives
- Supportive benefits and policies
- Establishment of communications channels
- Access to community resources
- Evaluation
Post-pregnancy and infancy period
In addition to implementing health promotion programs and other services that focus on a mother’s health before and during pregnancy, many employers also offer programs that support parents and infants after pregnancy, during the critical first twelve months and beyond. Maternity disability benefits, lactation programs, dependant care reimbursement accounts (e.g., pre-tax set-asides of earnings that employees may draw on to pay for dependant care expenses), parenting classes and onsite child care are just a few of the benefits and programs now offered.
For example, to maintain goodwill with its employees, Lancaster Laboratories, based in Lancaster, Pennsylvania, and providing contract laboratory research and consulting to the environmental, food and pharmaceutical industries, continues to provide health care insurance benefits during both maternity disability leave and unpaid parental leave whether or not the employee plans to return to work after having given birth. This family-supportive management approach has gotten results: in an industry where a 27% turnover rate is the norm, the rate at Lancaster is only 8% (March of Dimes 1994).
Lactation programs also are easy and beneficial for employers to implement. The health benefits of breastfeeding extend beyond the child’s own. A recent study shows that improving an infant’s health through breastfeeding has a direct effect on employee productivity. Healthier infants mean mothers and fathers miss significantly fewer days of work to care for a sick child (Ryan and Martinez 1989). Offering a lactation program simply requires providing onsite space and equipment for pumping and storing breast milk.
The Los Angeles Department of Water and Power was able to quantify some benefits of its lactation program: for example, 86% of participants state that the program eased their transition back to work; 71% report taking less time off since participating; and program participants have a 2% turnover rate (March of Dimes 1994).
Employer Policies
There are many workplace policies that employers can initiate to create a maternal and infant-health supportive culture. Instituting new policies and changing old ones can send an important message to employees about the company’s corporate culture.
Some policies affect the health of all workers, like creating a smoke-free environment. Others focus on selected groups, such as those that address occupational reproductive health hazards and which are targeted to meet the needs of men and women who are planning to have a child. Still more, including flexible work policies, support pregnant women in scheduling prenatal visits and ease the burden of parents with infants and small children. Finally, policies relating to modifying work assignments when needed during pregnancy and resolving questions of disability and its duration help to protect the health of the pregnant worker while minimizing interference with her work assignments.
When the Warner-Lambert Company, a leader in the pharmaceutical, consumer health care and confectionary products industries, initiated its maternity management and prenatal education programs, the company also introduced comprehensive guidelines for managing reproductive health. The guidelines encourage employees to complete questionnaires assessing the potential of reproductive health hazards in their jobs or worksites. If necessary, a Warner-Lambert safety engineer will conduct an assessment to determine what, if any, control of workplace hazards or job restrictions may be necessary.
In addition to reproductive health hazards policies, a number of employers offer flexible family leave policies. For example, at AT&T, the communications giant, employees can take up to 12 months of unpaid leave to care for a newborn or adopted child. More than 50% of the employees who have taken advantage of this leave policy since 1990 returned to work within three months. Within six months, 82% of the employees were back at work (March of Dimes 1994).
And at PepsiCo Inc., the large beverage and food conglomerate based in Purchase, New York, fathers of newborns can take up to eight weeks of paid leave and an additional eight weeks of unpaid leave with a guarantee of the same or a comparable job when they return (March of Dimes 1994).
Designing a Maternal and Infant Health Strategy to Meet Business Needs
Any sustainable employer-based maternal and infant health strategy, in addition to being acceptable to employees, must meet sound business objectives. Depending on a company’s objectives, different benefits, employee programs, or policies may take priority. The following steps are useful in developing a preliminary strategy:
- Document existing benefits, programmes, and policies that support maternal and infant health in order to create the foundation of a formal strategy.
- Find out about community resources available to assist the company’s efforts.
- Prepare a prioritized list of preliminary maternal and infant health initiatives which includes changes or introductions in benefits, programmes, or policies.
- Gain preliminary support from top management before taking the next step.
- Assess perceived needs and test proposed strategies with employees to validate preliminary recommendations.
- Develop a formal maternal and infant health strategy by articulating a mission, outlining objectives, allocating the resources needed, identifying potential obstacles and key players, preparing an implementation timetable and gaining necessary support at all levels of the company.
Implementing maternal and infant health initiatives
The next step is to implement the benefits, programs and policies that are part of the strategy. The implementation process typically includes the following steps:
- Assign responsibility for implementation.
- Select quality measurements by which to manage the programme.
- Evaluate and select vendors.
- Review incentives and other methods to increase employee participation.
- Communicate initiatives to employees and family members.
Managing the success of a maternal and infant health strategy
After implementation, an employer’s maternal and infant health strategy should be reviewed for effectiveness in meeting original objectives and business needs. Evaluation and feedback are essential and help to ensure that the maternal and infant health initiatives are meeting both the employer’s and employees’ needs.
Mother and Child Health in France
Shortly after World War II, France instituted Protection maternelle et infantile (PMI), a nationwide system through which public and private health professionals, in collaboration with social services, provide basic preventive health, medical, social and educational services to pregnant women, infants and children through to the age of six.
For the most part, families and private physicians arrange individually for preconception counseling, family planning, early and regular prenatal care and preventive health examinations and vaccinations for children up to the age of six. Participation in the program is encouraged through 100% reimbursement by national health insurance (in order to qualify for this coverage, women must register their pregnancies by the 15th week of gestation), monthly (family) allowance payments from a woman’s fourth month of gestation through to the child’s third month of life as an incentive for compliance with the national guidelines for preventive care, and a continuing program of information and education.
Women not able to participate in care via the private sector are covered by 96 locally controlled PMI centers, one in each French département. In addition to providing free neighborhood health clinics, these centers identify and target for intervention pregnant women and children at risk, conduct home visits and monitor the progress of all women and infants to ensure that the preventive services called for in the national guidelines are received.
The employers’ role in this system is regulated by law. They provide pregnant women with:
- Job changes; flexible hours to ease commuting burdens and rest periods in order to reduce the stress and fatigue that may lead to premature delivery
- Maternity leave with job security for mothers who bear or adopt children to promote bonding and healthy child development (a maternity benefit amounting to 84% of the salary, is paid by social security up to a ceiling)
- Part-time work arrangements and unpaid parental leave with job security to enable parents to balance child care and work responsibilities (a national parental allowance helps to offset the cost of the unpaid leave) (Richardson 1994)
Conclusion
The need to address maternal and infant health in the American workplace will increase as more and more women enter the labor force and as family and workplace issues become inseparable. Forward-thinking companies have already recognized this and are developing innovative approaches. Employers are in a unique and powerful position to influence change and become leaders in promoting healthy mothers and babies.