Prenatal Care

Prenatal care refers to medical care and other health-related services offered during pregnancy to ensure the well-being of the mother and her future offspring. Medical visits for prenatal care follow the pattern recommended by the American College of Obstetricians and Gynecologists (ACOG): an initial visit in the first trimester, one visit every four weeks through twenty-eight weeks of gestational age, then a visit every two weeks until thirty-six weeks, and then a visit every week through forty weeks (or until delivery). This pattern results in thirteen prenatal care visits for a normal length pregnancy. The emphasis on more visits at the end of pregnancy reflects the historical roots of prenatal care in the detection of preeclampsia/ eclampsia, a systemic hypertensive-related disorder that traditionally was the leading cause of maternal mortality.

The initial prenatal care visit involves taking a thorough obstetric history; establishing the gestation-al age of the fetus and the expected due date; assessing the initial level of risk to ensure appropriate level of treatment; initiating serial surveillance of fetal and maternal biologic markers to ensure that the pregnancy is following a normal developmental trajectory (e.g., physical exams, laboratory tests); and providing general prenatal education and psychosocial support. Subsequent visits involve continued serial surveillance, psychosocial support, and childbirth and post-partum education. Women with high-risk conditions, such as diabetes, elevated blood pressure, sexually transmitted diseases, and twins, may be followed more closely or referred to high-risk prenatal care specialists.

While the timing of prenatal care visits is well established, the content of the visits continues to evolve. New tests and procedures—such as alpha-fetoprotein, amniocentesis, genetic testing, sexually transmitted disease detection, and ultrasound—have emerged and have increased the physician's capacity to monitor the health of the mother and the growing fetus.

Although prenatal care as a formal medical service began in the early 1900s as part of the newly emerging obstetric profession's efforts to reduce maternal mortality, more recently the primary focus of prenatal care has increasingly shifted toward improving the health of the newborn. This shift has been accompanied by an expansion of prenatal health care to address a broader, more comprehensive range of health and social services that affect infant health. In 1965, as part of the War on Poverty, the federal Maternal and Infant Care project provided funds, for the first time, for social workers, health educators, and nutritionists to augment traditional medical services at the then newly inaugurated community health centers. This broadening of prenatal care reflected recognition of the larger social health context of a pregnancy, the limits of medical care alone to improve birth outcomes, and the increased focus on infant outcome.

Increasing Access to Prenatal Care

The 1980s saw a proliferation of public and private efforts to increase access to comprehensive prenatal care, as health experts concluded that such care was the public health solution for reducing the high infant mortality rates in the United States and for decreasing racial disparities in poor birth outcomes. The seminal 1985 Institute of Medicine report on Preventing Low Birthweight (LBW), in particular, strongly encouraged public efforts to increase the availability and comprehensiveness of prenatal care to reduce LBW. The report noted that prenatal care was widely perceived to be effective at reducing LBW and was cost effective ($3.38 saved for every dollar spent); it envisioned a more comprehensive version of prenatal care with strong psychosocial content.

Numerous federal, state, and philanthropic efforts were undertaken in this period. The U.S. National Commission to Prevent Infant Mortality was established; the Healthy Mothers, Healthy Babies Coalition was formed; the March of Dimes initiated the program Toward Improving the Outcome of Pregnancy; numerous state infant mortality commissions were started; and several new federal infant mortality reduction programs were undertaken (e.g., Healthy Futures/Healthy Generations, Healthy Start Initiative). A major federal report on the Content of Prenatal Care, published in 1989, also increased the focus on psychosocial and comprehensive prenatal care.

The most significant achievement of this period was the expansion of Medicaid in the late 1980s, which increased eligibility for prenatal care services by delinking Medicaid eligibility from welfare eligibility (specifically, the Aid to Families with Dependent Children program), and fostered more comprehensive prenatal care by allowing Medicaid to pay for numerous nonmedical prenatal services. Medicaid now could enroll and pay for the costs of prenatal care and delivery of all poorer women (those with an income of less than 185 percent of the poverty level), regardless of their marital status. Medicaid could also pay for any case-management, home visitation, nutrition, social work, and health education services that are needed. By the early twenty-first century, Medicaid was covering the costs of more than 40 percent of births in the United States.

In 1980, the U.S. government set as one of its 1990 National Health objectives that 90 percent of all pregnancies begin prenatal care in the first trimester. By the end of the twentieth century, the United States had still not reached this goal, and it therefore became a Healthy People 2010 objective. According to federal statistics from 1998, 82.8 percent of all mothers began prenatal care in the first trimester. This figure rose steadily in 1990s from 75.8 percent, after a decade-long period of no change. The increase in early usage was most likely due to the numerous federal efforts initiated in the late 1980s. The figures also revealed substantial disparities by race: 87.9 percent of white mothers started prenatal care in the first tri

There has been a recent refocusing of prenatal care to address issues of maternal health, such as diabetes, obesity, and hypertension. For many women, regular exercise and careful dietary controls throughout pregnancy have led to better overall maternal health. (Owen Franken/Corbis)

mester, compared to 73.3 percent of black, 74.3 percent of Hispanic, and 83.1 percent of Asian mothers.

More comprehensive utilization measures, such as the Kotelchuck Adequacy of Prenatal Care Utilization (APNCU) Index, also use number of visits and length of gestation, in addition to the timing of initial care, to assess the ACOG prenatal care standards. These indexes suggest an even more somber picture of prenatal care usage in the United States. For example, the APNCU Index reveals that only 74.3 percent of pregnant women have adequate prenatal care, 13.8 percent intermediate care, and 16.9 percent inadequate care, with correspondingly worse figures for African Americans, Hispanic Americans, and Asian Americans. Interestingly, more than 31 percent of U.S. women have more than the ACOG recommended number of visits, a percentage that increased substantially from the 24 percent level of 1990.

Barriers to the Use of Prenatal Care

A variety of barriers to the use of prenatal care have been identified. In 1988 the Institute of Medicine cited four groups of barriers: financial; inadequate systems capacity; organization, practices, and atmosphere of prenatal services; and cultural/ personal. Financial barriers have largely, but not completely, been addressed by the recent expansions of Medicaid eligibility and by reforms in health insurance, which have mandated pregnancy coverage. Immigration status and enrollment barriers, however, still influence access to Medicaid coverage. Transportation remains a major structural barrier to care in both urban and rural areas. Teens generally start prenatal care late. Organizational and personal factors, such as disrespect by providers, lack of planned pregnancy, not valuing prenatal care, and fear of detection of drug usage, remain substantial barriers to early and continuous prenatal care.

The content of care should be equal for all women, regardless of the source of their care, but this may not be the case. In general, prenatal care is more comprehensive in public clinics (including that among equally low-income women, public clinics make more referrals to the federal Women, Infants, and Children (WIC) nutrition program than private doctor's offices do). There is some evidence that providers offer different prenatal care content depending on the race and social class of their clients. And white women participate in childbirth education classes much more often than do African-American women.

The Relation between Prenatal Care and Birth Outcomes

Although it is widely believed that prenatal care is associated with better birth outcomes, the actual association is more complex. Early case-control/ correlational research in the 1960s and 1970s generally showed a small positive association between increased medical prenatal care and decreased low birthweight and infant mortality. More recent, rigorous studies, however, have not generally demonstrated significant associations with improved birth outcomes.

Several factors complicate this widely assumed positive association. First, the association between prenatal care visits and birth outcomes is not linear but U-shaped. Both less (inadequate) care and more (possibly medically needy) care are associated with increased poor birth outcomes. Second, women who participate in prenatal care enhancement programs may be a more self-selected group of health-conscious women, a factor that may be more important to improving birth outcomes than their use of more enhanced prenatal care. Third, research has not consistently demonstrated a strong impact of psychosocial factors on LBW, prematurity, and infant mortality. Much attention has shifted to the role of infectious diseases, such as bacterial vaginosis, in occurrences of prematurity, an example of a biologic factor in contrast to social factors. Fourth, almost all the late twentieth century improvements in infant mortality rates resulted from improvements in keeping LBW babies alive through improved neonatal care, not the prevention of low birthweight infants (the presumed pathway of prenatal care). And finally, there has been an increase in LBW and prematurity rates in the United States, despite simultaneous broad improvements in prenatal care overall. The policy and programmatic enthusiasm of the 1980s and 1990s for access to comprehensive prenatal care to address poor birth outcomes and racial disparities had greatly diminished by the early twenty-first century.

Trends in Prenatal Care

Several new trends in prenatal care efforts have emerged. First, reflecting the popular aphorism that ''you can't solve a lifetime of ills in nine months of a pregnancy,'' there has been an increasing focus on pre-conceptual care. Pre-conceptual care tries to detect and treat key maternal health issues prior to the beginning of the pregnancy. Examples include reduction of smoking, initiation of diabetes treatment, dietary improvement, and family planning. Pre-conceptual care links prenatal/reproductive care to the broader women's health movement. Second, there has been an increasing focus on providing specific ''proven'' prenatal care content rather than simply increasing the number of generic prenatal care visits. In this way, prenatal care has increasingly focused on such areas as smoking reduction, substance use reduction, diabetes treatment, WIC/nutrition supplementation, folic acid consumption, genetic testing, and HIV treatment. Third, there has been a further expansion of prenatal care psychosocial content to address newer and possibly more potent health risk factors, such as spousal violence and environmental risks. Finally, there has been a refocusing of prenatal care to once again address issues of maternal health and to not simply focus on birth outcomes (i.e., examining the impact of pregnancy on women's health, not simply the impact of women's health on pregnancy outcomes). Such an orientation focuses on prenatal to postnatal continuities in maternal depression, obesity, hypertension, and diabetes, as well as postpartum linkage to health services and satisfaction with care.

Beyond attempting to reduce the number of infants born small and premature, U.S. public health and clinical efforts to improve prenatal care usage and content have not generally been directly linked to child development programs. The federal funding sources that address these two developmental periods have been generally quite distinct. The temporal focus of some of the relevant professions has not generally overlapped, which further adds to their discontinuity. For example, obstetricians and public health maternity workers may have little interaction with pediatricians.

There are, however, increasing areas of overlap between prenatal care and child development efforts. There is increased recognition that many of the same high-risk families are being seen in both public prenatal care and child development programs. Maternal well-being (both physical and psychosocial) is critical in both the prenatal and postnatal periods. Comprehensive prenatal care now includes many of the same interventions as child development: home visitation, parent education, etc. In turn, the child development community is increasingly recognizing the importance of prenatal factors (including prenatal care) on subsequent infant and child functioning. There is a growing number of federal programs that try to improve both the reproductive and child developmental domains, including Medicaid, WIC, Early Intervention, and Title V. The newly revised Healthy Start program (the largest federal initiative dedicated to reproductive health) also has a focus on maternal and infant health from pregnancy through the first two years of an infant's life.

Prenatal care remains primary care for women in pregnancy. Its impact on both maternal health and newborn health reflects the evolving knowledge about its content and society's ability to ensure universal access.

See also: BIRTHWEIGHT; HEALTHY START; INFANT

MORTALITY; PREGNANCY

Bibliography

Alexander, Greg, and Carol Korenbrot. "The Role of Prenatal Care in Preventing Low Birth Weight.'' The Future of Children 5 (1995):103-120.

Alexander, Greg, and Milton Kotelcuck. ''Quantifying the Adequacy of Prenatal Care: A Comparison of Indices.'' Public Health Reports 111 (1996):408-418.

Fiscella, Kevin. "Does Prenatal Care Improve Birth Outcomes? A Critical Review.'' Obstetrics and Gynecology 85 (1995):468-479.

Kogan, Michael, Greg Alexander, Milton Kotelchuck, and David Nagey. ''Relation of the Content of Prenatal Care to the Risk of Low Birth Weight.'' Journal of the American Medical Association 271 (1994):1340-1345.

Kogan, Michael, Joyce Martin, Greg Alexander, Milton Kotelchuck, Stephanie Ventura, and Fredric Figoletto. ''The Changing Pattern of Prenatal Care Utilization in the United States, 1981-1995, Using Different Prenatal Care Indices.'' Journal of the American Medical Association 279 (1998):1623-1628.

Merkatz, Irwin, Joyce Thompson, Patricia Mullen, and Robert Goldenberg. New Perspectives on Prenatal Care. New York: Elsevier Science Publishing, 1990.

Milton Kotelchuck

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