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Inadequate Prenatal Care Utilization and Risks of Infant Mortality and Poor Birth Outcome: A Retrospective Analysis of 28,729,765 U.S. Deliveries over 8 Years

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Objective: To evaluate the association between adequacy of prenatal care utilization and risk of fetal and neonatal mortality and adverse outcomes. Methods: We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all deliveries in the United States between 1995 and 2002. Inclusion criteria were singleton births ≥22 weeks of gestation with no known congenital malformation. Inadequate prenatal care was defined according to the Adequacy of Prenatal Care Utilization Index, and its effect on fetal and neonatal death was estimated using unconditional logistic regression analysis adjusting for maternal age, race, education, and other confounding variables. Results: During our 8-year study period, 32,206,417 births occurred, 28,729,765 (89.2%) of which met inclusion criteria. Inadequate prenatal care utilization occurred in 11.2% of expectant mothers, more commonly among women ≤20 years, black non-Hispanic and Hispanic women, and those without high school education. Relative to adequate care, inadequate care was associated with increased risk of prematurity 3.75 (3.73 to 3.77), stillbirth 1.94 (1.89 to 1.99), early neonatal dearth 2.03 (1.97 to 2.09), late neonatal death 1.67 (1.59 to 1.76), and infant death 1.79 (1.76 to 1.82). Conclusion: Risk of prematurity, stillbirth, early and late neonatal death, and infant death increased linearly with decreasing care. Given the population effect of this association, public health initiatives should target program expansion to ensure timely and adequate access, particularly for women ≤20 years, Black non-Hispanic and Hispanic women, and those without high school education.
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Inadequate Prenatal Care Utilization and Risks
of Infant Mortality and Poor Birth Outcome:
A Retrospective Analysis of 28,729,765 U.S.
Deliveries over 8 Years
Sarah Partridge, M.D., B.Sc. 1Jacques Balayla, M.D. 1Christina A. Holcroft, Sc.D. 1
Haim A. Abenhaim, M.D., M.P.H.1
1Centre for Clinical Epidemiology and Community Studies, Jewish
General Hospital, Montreal, Quebec, Canada
Am J Perinatol 2012;29:787794.
Address for correspondence and reprint requests Haim A. Abenhaim,
M.D., M.P.H., F.R.C.S.C., Department of Obstetrics and Gynecology,
Jewish General Hospital, McGill University, Pav H, 325, 5790 Cote-
Des-Neiges, Montréal, QC H3S 1Y9, Canada
(e-mail: haim.abenhaim@gmail.com).
Adequate prenatal care (PNC) is a widely accepted determi-
nant of maternal and child health and a focus of public health
programming, despite ongoing controversy over whether
PNC prevents poor birth outcomes, particularly infant mor-
tality. PNC is considered adequate, based on the American
College of Obstetricians and Gynecologists guidelines for
prenatal visits in low-risk pregnancy, if it is initiated in the
rst trimester with regular visits of increasing frequency as
term approaches.1There is an absence of high-quality evi-
dence from randomized controlled trials to establish either
Keywords
prenatal care
risk factors
pregnancy outcome
infant mortality
population
characteristics
Abstract Objective To evaluate the association between adequacy of prenatal care utilization
and risk of fetal and neonatal mortalit y and adverse outcomes.
Methods We conducted a population-based cohort study using the Center for Disease
Control and Preventions Linked Birth-Infant Death and Fetal Death data on all deliveries
in the United States between 1995 and 2002. Inclusion criteria were singleton births
!22 weeks of gestation with no known congenital malformation. Inadequate prenatal
care was dened according to the Adequacy of Prenatal Care Utilization Index, and its
effect on fetal and neonatal death was estimated using unconditional logistic regression
analysis adjusting for maternal age, race, education, and other confounding variables.
Results During our 8-year study period, 32,206,417 births occurred, 28,729,765
(89.2%) of which met inclusion criteria. Inadequate prenatal care utilization occurred
in 11.2% of expectant mothers, more commonly among women "20 years, black non-
Hispanic and Hispanic women, and those without high school education. Relative to
adequate care, inadequate care was associated with increased risk of prematurity 3.75
(3.73 to 3.77), stillbirth 1.94 (1.89 to 1.99), early neonatal dearth 2.03 (1.97 to 2.09),
late neonatal death 1.67 (1.59 to 1.76), and infant death 1.79 (1.76 to 1.82).
Conclusion Risk of prematurity, stillbirth, early and late neonatal death, and infant
death increased linearly with decreasing care. Given the population effect of this
association, public health initiatives should target program expansion to ensure timely
and adequate access, particularly for women "20 years, Black non-Hispanic and
Hispanic women, and those without high school education.
received
October 27, 2011
accepted after revision
February 29, 2012
published online
July 26, 2012
Copyright © 2012 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI http://dx.doi.org/
10.1055/s-0032-1316439.
ISSN 0735-1631.
Original Article 787
Downloaded by: McGill University. Copyrighted material.
the overall benetofPNCorwhatfrequencyorcontentofcare
has maximal benet. Observational and retrospective cohort
studies have yielded conicting results: Some failed to estab-
lish prevention of poor outcomes,24but others showed that
minimal or no PNC is associated with low birth weight,
preterm birth, or being small for gestational age.49Trial s
comparing reduced to standard PNC had insufcient power to
expose associations with infant mortality.10,11 Limitations in
the denition and measurement of adequate care may un-
derlie these conicting results.
Despite dramatic declines in U.S.infant mortality rates over
the past 50 years, there has been an increasing disparity in
infant mortality rate by race and maternal education, which
has been thought to be in part due to discrepancies in access to
or utilization of adequate PNC.12 Unfort unately, given the
paucity of evidence measuring associations between PNC
and perinatal mortality, justication for public health initia-
tives promoting the implementation of programs increasing
access to timely and adequate PNC may be limited given the
increasing overall costs of health care in Westernized coun-
tries. The purpose of our study was thus to measurethe rates of
inadequate PNC as dened by the Adequacy of Prenatal Care
Utilization (APNCU) index and estimate the magnitude of the
relationship between inadequate care and fetal and neonatal
mortality.13 We used a large administrat ive dat abase of over
32 million births over 8 years to ensure sufcient power to
detect differences in mortality that may exist.
Materials and Methods
We conducted a r et ro spec tive cohort st udy for 8 consecu tive
years, from 1995 to 2002, using the Birth Cohort Linked
Birth-Infant Deathand the Fetal Deathdata les from the
National Center for Health Statistics (Centers for Disease
Control and Prevention). The birth cohort les contain infor-
mation on #3.5 million live births per year to residents and
nonresidents in the United States. This information is ob-
tained from the birth certicate and is available for all births.
The infant death le contains information on all infant deaths
in the United States and can be linked to its corresponding
birth record in the birth cohort through a unique identier.
The fetal death cohort le contains the record on all fetal
deaths and can be readily appended to the live birth cohort
le to obtain a nal cohort containing all deliveries, whether
born dead or alive. We selected from these databases all
records for the contiguous United States, Hawaii, and Alaska.
The territories Puerto Rico, Guam, and the Virgin Islands were
excluded from our cohort. Furthermore, our analysis did not
include births of U.S. cit izens outside of the United States. This
resulted in an aggregate of 32,206,417 deliveries. We
then sequentially excluded all nonsingleton gestations
(1,287,495); deliveries that occurred prior to 22 weeks
(317,135) or after 44 weeks of gestational age (944,273)
and those with a congenital anomaly reported on the birth
certicate (1,244,884). This resulted in an 8-year cohort of
28,729,765 deliveries.
The variables used in this analysis were dened as follows.
The APNCU index is a sum of two independent dimensions:
Adequacy of Initiation of PNC and Adequacy of Received
Services (a ratio of PNC visits completed relative to those
expected based on gestational age and the American Congress
of Gynecologists and Obstetricians recommended PNC sched-
ule for low-risk pregnancies). Deliveries were categorized by
receipt of, in increasing order of PNC utilization, inadequate
care(initiated after 4 monthsgestation or fewer than half of
predicted visits), intermediate care(initiated prior to
4monthsandbetween50%and79%ofexpectedvisits),
adequate care(initiated by 4 months and 80 to 109% of
expected visits), or adequate-plus care(initiated by
4monthsand110%ormoreofexpectedvisits).Anal group,
missing care data,was created for cases where PNC ade-
quacy could not be calculated due to the absence of essential
information. The following variables were used to calculate
the APNCU with a previously published SAS algorithm dis-
tributed by Dr. Milton Kotelchuck, developer of the APNCU
index14,15:gestationalageatinitiationofPNC(2-month
intervals), total number of PNC visits (excluding hospital-
izations), and the gestational age in weeks. In the event of
missing gestational age data, the gestat ional age was imputed
from the sex and birth weight. Improbable birth weight (less
than 250 g and more than 4999 g) was corrected for.
Birth outcomes included small for gestational age (SGA)
and intrauterine growth restriction (IUGR), respectively de-
ned as birth weight below the 10th and 3rd percentiles, and
large for gestational age (LGA), dened as birth weight above
the 90th percentile, using a standard reference developed for
male and female singleton births.16 Preterm birth was de-
ned as live birth under 37 weeksgestation. Stillbirth was
dened, based on the 1950 World Health Organization de-
nition, as an intrauterine demise irrespective of the duration
of pregnancy and excluding all induced terminations of
pregnancy. Stillbirths with missing gestational age data
were proportionally distributed across gestational ages and
thus were unlikely to represent a signicant confounding
factor. Early neonatal death was dened as any infant death
that occurred from birth to 7 days; late neonatal as death
between 7 and 27 days; and infant death as any fatality
between birth and 365 days of life. Deliveries that had
incomplete records were included in the analysis, through
the creation of dummy values to represent missing data.
Our analysis was conducted in three steps. First, we
performed descriptive statistics for the annual frequency
distribution of APNCU categories from 1995 to 2002. Second,
we did a sensitivity analysis to investigate the robustness of
our ndings, as there was possible bias introduced by incom-
plete or inconsistent data collection. We examined the ma-
ternal and gestational characteristics of each APNCU class.
These characteristics were the maternal age (10-year inter-
vals), maternal race (white non-Hispanic, black non-Hispan ic,
Hispanic, or other non-Hispanic), maternal education (in
years), marital status (married, not married), parity (zero,
one, two, three or more prior births), smoking during the
pregnancy (yes, no), and alcohol consumption during the
pregnancy (yes, no). Finally, we performed logistic regression
analysis to estimate the cr ude and adjusted odds ratio of eight
poor birth outcomes for each APNCU category. All outcomes
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Inadequate Prenatal Care Utilization Partridge et al.788
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were modeled separately. We dened adequate care as the
reference group and calculated 95% condence intervals. The
eight outcomes of interest were: SGA, IUGR, LGA, preterm
birth, stillbirth, early neonatal death, late neonatal death, and
infant death. All outcomes were adjusted for maternal age,
maternal race, maternal education, marital status, parity,
maternal smoking, or alcohol consumption during pregnan-
cy. All analyses were conducted using SAS version 9.2 (SAS
Institute, Cary, NC). This protocol was approved by the
Medical Research Ethics Department of the Jewish General
Hospital in Montreal, Quebec.
Results
Of the 32,206,417 births recorded during our 8-year study
period, 28,729,765 (89.2%) met the study inclusion criteria. In
the rst analysis, we examined the frequency distribution of
deliveries from 1995 to 2002 by APNCU class. Despite annual
uctuations in the relative proportions of each class, the
percent annual frequency of the intermediate and adequate
care groups was relatively stable over 8 years (Fig. 1).
Inadequate care showed modest decreases each year, chang-
ing overall from 11.8% in 1995 to 10.74% in 2002; this was
offset by an increase in adequate-plus care from 27.6% in 1995
to 30.0% in 2002.
Table 1 summarizes sociodemographic and gestational
characteristics by APNCU group. The proportion of mothers
receiving inadequate care was greatest among those under
15 and 15 to 19 years of age, black non-Hispanic or Hispanic,
not married, with less than 12 years of education, with three
or more prior live births, and with smoking or drinking
alcohol during the pregnancy. Among those who received
adequate care, there were proportionately more mothers
who were 30 to 39 years old, white non-Hispanic, married,
with greater tha n 16 years of education, who had one or fewer
prior live births. Most mothers received adequate care:
12,374,128 (43.1%).
Table 2 shows the odds ratio and frequency of stillbirth,
infant mortality, and adverse outcomes by APNCU category.
All outcomes were modeled separately; adequate care was
used as the reference, and results were signicant with
p<0.0001. Inadequate PNC was associated with increased
risk of all adverse outcomes. Stillbirth, early neonatal death,
late neonatal death, and infant death showed a linear increase
in risk with decreasing PNC relative to adequate care. There
was a bimodal distribution according to PNC, with the great-
est risks associated with the adequate-plus care and missing
care data groups. The adequate-plus care group had reduced
risk of IUGR and SGA and more risk of LGA; this group also had
asubstantiallyincreasedriskofpretermbirth.Adjustingfor
confounding variables reduced risk estimates for a ll outcomes
(nonadjusted data not reported).
Table 3 shows a subgroup analysis of 27,900,165 births at
34 or more weeksgestation, with odds ratio and frequency of
stillbirth, early neonatal death, late neonatal death, and infant
death by APNCU category. All outcomes were modeled and
corrected for in a fashion identical to the analysis in Table 2
and were signicant with p<0.0001. The linear relationship
between risk of adverse outcome and decreasing PNC was
preserved; however, the odds ratios were notably smaller.
Discussion
Adequacy of PNC utilization is an important predictor of
maternal and fetal health. Over an 8-year span from 1995
to 2002, a consistent annual decrease in rates of inadequate
care was offset by a rise in rates of adequate-plus care. The
proportion of mothers receiving inadequate care was greatest
among women under 20 years of age who were black non-
Hispanic or Hispanic, were not married, had less than 12 years
of education, had three or more prior live births, and smoked
or drank alcohol during the pregnancy. Inadequate PNC was
associated with increased risk for all adverse outcomes of
interest. Risk of prematurity, stillbirth, early neonatal death,
Figure 1 Percent annual frequency by Adequacy of Prenatal Care Utilization (APNCU) class 19952002.
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late neonatal death, and infant death increased linearly with
decreasing PNC. Inadequate PNC utilization was associated
with an increased risk of poor birth outcomes; however,
patients with above-adequate care and missing PNC data
also had substantial risk.
To date the most widely used indices of PNC utilization are
the Kessner and the APNCU Index. The Kessner Index was
developed in 197317 and largely did not show differences in
outcome between groups, possibly secondary to inadequate
separation of groups. 15 In the 1990s, Kotelchuck proposed the
APNCU Index as a modication of the Kessner: Its most
interesting contribution is the distinction of patients with
adequate-plus care who previously had been included in the
adequate care group. The adequate-plus care group has since
been demonstrated to have poor birth outcomes, and it has
been suggested that inclusion of high-risk patients in the
reference group may have obscured relationships between
PNC and outcome.13 The APNCU has also been shown to
generate a smaller inadequate care group than the Kessner,
which is likely a more precise categorization.18 For these
reasons, we elected to use the APNCU Index.
Our nding of a signicant association between PNC and
infant mortality is consistent with that of a random sample
from the 2003 Centers for Disease Con trol birth cohort, where
inadequate care had a twofold increase in risk of infant
mortality relative to adequate care.19 Our nding of a linear
relationship between decreasing PNC and increasing risk of
stillbirth, early neonatal death, late neonatal death, and infant
Table 1 Baseline Characteristics by APNCU Prenatal Care Category
APNCU Category
Missing Care Data
(n¼1,063,776), %
Inadequate Care
(n¼3,224,001), %
Intermediate Care
(n¼3,765,225), %
Adequate Care
(n¼12,374,128), %
Adequate-Plus Care
(n¼8,302,635), %
Age (y)
<15 5.6 32.1 11.8 27.1 23.4
1519 4.5 20.3 13.5 35.8 26.0
2029 3.7 11.7 53.0 42.8 28.5
3039 3.4 7.0 12.7 46.5 30.4
>39 4.0 9.4 11.6 41.2 33.7
Race
White non-Hispanic 2.7 7.3 12.6 47.3 30.1
Black non-Hispanic 5.7 18.4 12.4 34.0 29.5
Hispanic 4.8 17.4 14.7 37.3 25.8
Other non-Hispanic 3.9 12.6 14.6 42.5 26.5
Unknown 10.2 9.9 15.1 41.3 23.5
Marital status
Married 3.1 7.1 13.0 46.7 30.0
Not married 4.9 19.6 13.4 35.6 26.5
Maternal education (y)
08 4.8 25.1 15.5 32.4 22.1
911 4.6 21.2 14.0 34.5 25.6
12 3.7 11.8 13.1 42.0 29.3
1315 2.9 7.2 12.5 46.0 31.3
>16 2.6 3.6 12.4 50.9 30.5
Prior live births
None 3.5 9.8 12.8 44.1 29.8
One 3.3 9.6 13.2 44.7 29.2
Two 3.7 12.2 13.5 42.2 28.4
Three or more 4.7 20.2 14.0 35.9 25.1
Smoking during pregnancy
Yes 3.8 16.6 13.1 38.0 28.4
No 3.8 10.6 13.0 43.7 28.9
Alcohol during pregnancy
Yes 5.1 23.7 13.1 35.3 22.7
No 3.8 11.2 13.1 43.2 28.7
Table values are percentages rounded to one decimal, thus not all rows sum to 100%.
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Table 2 OR and Frequency of Outcome by APNCU Prenatal Care Category for the 19952002 Singleton Birth Cohort (n¼28,729,765)
APNCU Category
Missing Care Data
(n¼1,063,776)
Inadequate Care
(n¼3,224,001)
Intermediate Care
(n¼3,765,225)
Adequate Care
(n¼12,374,128)
Adequate -Plus Ca re
(n¼8,302,635)
% OR (95% CI) % OR (95% CI) % OR (95% CI) % Reference % OR (95% CI)
Preterm birth 16.3 4.77 (4.744.81) 13.3 3.75 (3.733.77) 3.5 1.05 (1.041.06) 3.1 1 22.5 9.10 (9.079.13)
IUGR 5.3 1.10 (1.091.11) 6.3 1.30 (1.291.31) 5.7 1.48 (1.471.49) 3.7 1 3.1 0.78 (0.780.79)
SGA 8.5 1.03 (1.021.04) 9. 7 1.11 (1.111.12) 9.4 1.26 (1.251.27) 7. 2 1 6.1 0.80 (0.790.80)
LGA 12.2 1.20 (1.191.21) 11.6 1.20 (1.191.20) 8.7 0.80 (0.800.80) 10.7 1 17.4 1.80 (1.791.80)
Stillbir th 1.0 1.07 (1.031.10) 0.7 1.94 (1 .891.99) 0.3 1. 21 (1.181.25) 0.3 1 0.6 2.24 (2.202.29)
Early neonatal death 0.6 4.44 (4.294.59) 0.2 2.03 (1.972.09) 0.1 1.20 (1.161. 24) 0.1 1 0.3 3.07 (3.003.14 )
Late neonatal death 0.1 2.80 (2.632.98) 0. 1 1.67 (1.591.76) 0.0 1.08 (1.021.15) 0. 0 1 0.1 2.52 (2.432.61)
Infant death 1.0 2.83 (2.772.90) 0. 7 1.79 (1.761.82) 0.3 1.14 (1.121.17) 0. 3 1 0.6 2.22 (2.192.26)
Each outcome modeled separately. All p<0.0001. Adjusted for maternal race, materna l age, marital status, maternal education, pri or live bir ths, and maternal smoking and matern al alcohol in pregnancy. APNCU,
Adequac y of Prenatal Care Utilization; CI, condence inter val; IUGR, intrauterine growth restric tion; LGA, large for gestational age; OR, odds ratio; SGA, small for gestational age.
Table 3 Births at 34 or More WeeksGestation: OR and Frequency of Outcome by APNCU Prenatal Care Category for the 19952002 Singleton Birth Cohort (n¼27,900,165)
APNCU Category
Missing Ca re Data
(n¼1,063,776)
Inadequate Care
(n¼3,224,001)
Intermediate Care
(n¼3,765,225)
Adequate Care
(n¼12,374,1 28)
Adequate-Plus Care
(n¼8,302,635)
% OR (95% CI) % OR (95% CI) % OR (95% CI) % Reference % OR (95% CI)
Stillbir th 0.47 0.68 (0.660.72) 0.24 1.76 (1.691.82) 0.16 1.32 (1.27 1.38) 0.11 1 0.16 1.46 (1.411.50)
Early neon atal death 0.09 2.27 (2.112.45) 0.06 1.72 (1.621.82 ) 0.04 1.23 (1.161.30) 0.03 1 0.05 1.63 (1.561.71)
Late neonatal death 0.05 1.60 (1.451.77) 0.05 1.45 (1.361.55) 0.03 1.11 (1.041.19) 0.03 1 0.04 1.42 (1.341.49)
Infant death 0.36 1.59 (1.531.65) 0.42 1.56 (1.531. 60) 0.23 1.14 (1.111.17) 0.18 1 0.25 1.34 (1.321.37)
Each outcome modeled separately. All p<0.0001. Adjus ted for maternal race, materna l age, marital status, maternal education, prior live bir ths, maternal smoking and maternal alcohol in pregnancy. APNCU,
Adequac y of Prenatal Care Utilization; CI, condence interval; OR, odds ratio.
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death supports a direct relationship. The relative risks of
adverse neonatal and infant outcomes by APNCU class were
smaller in a subgroup analysis of births at 34 or more weeks
gestation, suggesting that an association between inadequate
PNC and prematurity is involved in some poor outcomes.
The relationship between level of PNC and bir th outcomes can
be accounted for in a variety of ways. Some components of
PNC are clearly protective, such as diagnosis and treatment of
maternal genital tract infection,20 HIV infection,21 or promo-
tion of exclusivebreast-feeding.22 Another possibility is that a
maternal factor, such as care-seeking behavior, could, in
association with other health-promoting behaviors, account
for differential risk.2,23 This possibility is reinforced by evi-
dence that utilization of PNC is associated with increased
utilization of preconception care, infant care, and infant
vaccination.2426 This healthy adherer biaswas recently
described through a meta-a nalysis showing that patients who
adhere to drug therapy have lower all-cause mortality, even
when that therapy is a placebo, suggesting that patient
adherence may itself be a surrogate for health-promoting
behaviors.27 Adoption of PNC is likely multifactorial and can
be predicted by factors such as having an unplanned preg-
nancy, late recognition of pregnancy, race, socioeconomic
status, and geographic location.2831 Demographic character-
istics disproportionately prevalent in the inadequate care
group likely reect underlying heterogeneity in this group,
ranging from mothers under 15 years of age to multiparous
women who may not appreciate the need for PNC.
Our study showed that women with adequate-plus PNC
have an increased risk of perinatal mortalit y. It has previously
been suggested that this group contains disproportionately
more identied high-risk pregnancies that required more
prenatal visits and subsequent interventions.13,15 This possi-
bility is supported by our nding that this group also had
increased risk of LGA, perhaps reecting macrosomic infants
of diabetic mothers who are likely to be more closely followed
both before and during the pregnanc y than women who were
not diabetic. There may also be an iatrogenic contribution to
poor birth outcomes seen with above-adequate PNC: Mater-
nal care providers who are categorized as more aggressive
testershave a greater incidence of low birth weight, even
after risk factors were controlled for.32
An element of all studies that use large administrative
databases is the treatment of missing data. In their analysis of
Californian births, Gould et al found that incomplete records
were an independent and linearly related risk marker for
infant mortality.33 For this reason, we did not exclude
deliveries with incomplete records from our analysis and
elected to treat those with missing PNC data as a separate
subset of the population. This missing care data group had
the highest relative risk for early and late neonatal and infant
death. This relatively small subpopulation, with 1,063,776
deliveries over 8 years, may represent an important subset of
high-risk mothers who are largely unknown to the health
care system or a bias toward underdocumentation in some at
risk groups. With respect to cases where PNC data were
available, our results remained signicant despite the inclu-
sion of missing variables and likely underrepresent the true
relative risk, as the bias of inclusion of missing data are
toward the null.
One limitation of the APNCU index is a previously de-
scribed gestational age bias. Gestational age affects categori-
zation within the index and could be expected to have a
greater effect on some outcomes of interest, such as low birth
weight, than adequacy of PNC. Short gestation may result in
delivery before the opportunity to initiate care or misclassi-
cation in the adequate-plus category, as fewer visits are
recommended in early pregnancy and 110% utilization could
be met with one extra visit. Postdate gestations would require
more visits and thus be less likely to meet criter ia for inclusion
in the adequate-plus group. Our nding of a ninefold increase
in preterm birth for the adequate-plus group relative to the
adequate group likely reects this bias, and caution should be
used in the interpretation of prematurity risks in this context.
Gestational age bias can be overcome by the use of dependant
variables that correct for gestational age, such as SGA in place
of low birth weight,10,19,34,35 as we did in this study. A
comparison of four adequacy of care indices, including the
Kessner and the APNCU, showed comparable association
between PNC and SGA across indices, demonstrating the
robustness of this measure.19
Limitations of this study include the potential for an
ecological fallacy, whereby relationships between PNC and
outcome for the U.S. population as a whole may not apply to
subpopulations; there is evidence that some groups are at
greater risk for poor birth outcomes in the absence of PNC,
and these relationships bear further investigation.36 Use of
birth and death certicate data limited our assessment to an
analysis of adequacy as dened by utilization, rather than the
content of PNC. Reporting bias is also possible, as an indepen-
dent assessment of the quality of national birth record data
was not performed, and misclassication and measurement
error have previously been reported with birth certicate
data: 5.1% of prenatal visits were missing in birth certicates
relative to chart review in a sample of low-risk pregnancies in
Washington state from 1988 to 1 98 9. 37 In a study comparing
birth certicate data to medical records in New York for 1999,
the date of initiation of care was concordant within 1 week
for 76% of records; however, there was only a 38% absolute
concordance for the number of prenatal visits, which in-
creased to 70% with a two-visit range; last, the last menstrual
period was correct 87% of the time and was 93% accurate with
a1-weekrange.
38 Fortunately the large sample size this data
affords was sufcient to expose signicant associations even
with this source of statistical noise. Our study is, however,
unique in that it has considerable power to nd associations
with relatively rare outcomes.
In conclusion, this is the largest population-based cohort
study to date to evaluate the association between adequacy of
PNC utilization and the risk of adverse outcomes. We found a
strong linear association between inadequate PNC and in-
creased risk of prematurity, stillbirth, and neonatal and infant
mortality. This increase in risk may have a small effect for
individual mothers, but the population-level effect in a
country with more than 3.5 million annual singleton deliver-
ies is substantial. Mothers who disproportionately receive
American Journal of Perinatology Vol. 29 No. 10/2012
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inadequate care were under 20 years of age, black non-
Hispanic and Hispanic women, and those without high school
education. Given the population effect of this association,
public health initiatives should target program expansion to
ensure timely and adequate access to adequate PNC, particu-
larly for women at risk.
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... Because many risks for adverse birth outcomes are related to maternal health (DeFranco et al., 2008;Di Renzo et al., 2011;Meis et al., 1998;Smith et al., 2007;Valero et al., 2004) as well as require early intervention when complications arise (Laditka et al., 2005), assuring access to and utilization of prenatal care has been a cornerstone of efforts to improve birth outcomes. Obtaining adequate prenatal care has been related to lower risk of low birth weight and preterm births (Chen et al., 2007;Maupin et al., 2004;Taylor et al., 2005;Vintzileos et al., 2002;Partridge et al., 2012), and neonatal mortality (Barros et al., 1996). This study examines the effect of a comprehensive intervention to improve birth outcomes, the Toward Health Resiliency for Infant Vitality & Equity (THRIVE) program, on adequacy of prenatal care utilization, and specifically examines whether the program addresses racial disparities in prenatal care. ...
... Prenatal care utilization is a complex phenomenon. While many studies demonstrate better outcomes with adequate prenatal care (Chen et al., 2007;Maupin et al., 2004;Taylor et al., 2005;Vintzileos et al., 2002;Partridge et al., 2012), selection biases can exist, making it difficult to attribute differences in outcomes directly to the receipt of prenatal care. There are various explanations of what selection biases mean for the interpretation of these findings, with a comprehensive review concluding that these biases tend to result in underestimates of the role of prenatal care in birth outcomes (Frick & Lantz, 1996). ...
... Prenatal care utilization is shaped by factors related to demographic variables such as age, race/ethnicity, and education, with women who are Black Non-Hispanic or Hispanic, younger age, and who have less than a high school education, being less likely to have adequate prenatal care (Blakeney et al., 2019;Partridge et al., 2012). Between 2017 and 2019, Black women had the highest rates of inadequate prenatal care of any racial or ethnic group in Ohio, at 24.4%, compared to White women with 13.1% of births having inadequate care (March of Dimes, 2021). ...
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Article
Introduction The THRIVE (Toward Health Resiliency and Infant Vitality & Equity) program aims to reduce racial disparities in birth outcomes by addressing individual risks and social determinants of health using the Pathways Community HUB model. This study examines (1) racial disparities among THRIVE participants and propensity score matched (PSM) comparisons in adequacy of prenatal care, and whether THRIVE participation (2) attenuates such disparities, and (3) improves odds of having adequate prenatal care. Methods Birth certificate and Care Coordination Systems client data were merged for analysis. PSM was employed for 1:1 matching per birth year (2017–2020) and race for participating and non-participating first-time births in Stark County, Ohio. Additional matching variables were age, marital status, education attainment, birth quarter, census tract poverty rate, and Women Infant & Children (WIC) enrollment. Logistic regression assessed racial differences in adequate prenatal care utilization (APNCU) and examined differences between the intervention and comparison groups on APNCU. Results THRIVE participants averaged more prenatal care visits and had a higher percentage of adequate care utilization than the comparison group. THRIVE program participation, educational attainment, and WIC enrollment were associated with higher odds of adequate prenatal care utilization (OR 4.74; 95% CI 2.62, 8.57). Race was not significant for APNCU. Discussion Although accessing and maintaining prenatal care is only one aspect of improving birth outcomes, the findings contribute to the understanding of the effects of the program of interest and other similar programs on factors which may promote desired birth outcomes in high-risk populations.
... PNC encompasses "services provided to improve pregnancy outcomes and engage the expectant mother, family members, and friends in healthcare decisions" (Daniels & Mayberry, 2006). 1 Furthermore, it allows for pregnant individuals to be screened and treated for manageable conditions (Taylor 2005). Early PNC utilization is also associated with lower risk for adverse fetal outcomes such as low birth weight and preterm birth (Daniels & Mayberry, 2006;Debiec, Paul, Mitchell, & Hitti, 2010;Partridge, Balayla, Holcroft, & Abenheim, 2012), and lower maternal health risk during and after pregnancy (Yan, 2017). Lack of PNC is associated with a variety of adverse outcomes including: preterm birth, low birth weight, fetal death, stillbirth, and infant mortality (Maupin et al., 2004;Partridge et al., 2012;Taylor et al., 2005;Vintzileos et al., 2002a;Vintzileos et al., 2002b;Yan, 2017). ...
... Early PNC utilization is also associated with lower risk for adverse fetal outcomes such as low birth weight and preterm birth (Daniels & Mayberry, 2006;Debiec, Paul, Mitchell, & Hitti, 2010;Partridge, Balayla, Holcroft, & Abenheim, 2012), and lower maternal health risk during and after pregnancy (Yan, 2017). Lack of PNC is associated with a variety of adverse outcomes including: preterm birth, low birth weight, fetal death, stillbirth, and infant mortality (Maupin et al., 2004;Partridge et al., 2012;Taylor et al., 2005;Vintzileos et al., 2002a;Vintzileos et al., 2002b;Yan, 2017). ...
... Yet inadequate access to PNC remains a public health concern and policy focus (Debiec et al., 2010;Partridge et al., 2012;Yan, 2017). In 2019, approximately 6.4 percent of births (nearly 240,000 infants) in the U.S. received late or no PNC (March of Dimes, 2022). ...
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Article
•Fixed-effects analysis of fetal protection policies on prenatal healthcare utilization.•Original panel data examines changes across the United States between 2002 and 2015.•Certain policies are associated with fewer women utilizing prenatal healthcare when recommended.•State policies may have unintended consequences on maternal decision-making.
... Studies from several countries have found that poor ANC attendance is an important risk factor for adverse pregnancy outcomes [11,12]. As the number of ANC visits decreases, there was an increase in the risk of preterm birth and stillbirth [13][14][15][16]. Women who had no ANC follow-up and those who had an ANC visit less than four times during pregnancy were also found to have a low birth weight (LBW) baby [14,17,18]. ...
... Four new-borns had a known date of delivery, but their birth weight was not measured within 72 hours of delivery. Sixteen [16] of the Fig. 1 Flowchart of study participants included in the recruitment and outcomes of the study new-borns of pregnant women who were temporarily relocated for delivery to another place had a known date of delivery. Both date of delivery and birth weight were not known for 42 new-borns of the pregnant women who were temporarily relocated to another place for delivery. ...
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Article
Background Antenatal health care utilization has the potential to influence maternal and new-born health. In this study, we assessed compliance of antenatal care utilization with national and World Health Organization (WHO) guidelines. We also examined association of antenatal care utilization with adverse pregnancy outcomes as secondary outcome. Methods This was a community-based cross sectional study conducted from July 2016 to November 2017 in rural south-central Ethiopia. We described antenatal care received by pregnant women, whom we followed at three prescheduled visits during pregnancy and collected birth data at time of delivery. Extent of antenatal care content received, timing of antenatal care, place of antenatal care and place and mode of delivery were obtained and computed in accordance with national and WHO guidelines. For adverse pregnancy outcomes, computed as sum of low birth weight, preterm birth, intrauterine foetal death, and stillbirth, the exposure variable used was antenatal care utilization. Results Seven hundred and four (704) women participated in the study, and 536 (76.1%) had attended at least one antenatal care visit. Among women who attended antenatal care visit, majority, 421 (79.3%), had done so at health centres and hospitals, while 110 (20.7%) attended at health post. Average number of antenatal care visits was 2.5, which is less than that recommended in national and WHO guidelines. Only 18 (2.6%) women had attended antenatal care in their first trimester, which is low in contrast to the expected 100% specified in the guidelines. Less than half (47%) of the women delivered in a health facility. This is in contrast to the 100% expected health institution deliveries. Low birth weight was 7.9% ( n = 48), and preterm birth was 4.9% ( n = 31). There were 12 twin pregnancies, three stillbirths, 11 spontaneous abortions, and two intrauterine foetal deaths. We did not find significant association between adverse pregnancy outcomes and antenatal care utilization (COR = 1.07, 95% CI 0.62, 1.86). Conclusion This study showed that antenatal care service utilization in the study area was markedly low compared to that recommended in national and WHO guidelines. The obtained antenatal health care utilization was not associated with the registered adverse pregnancy outcomes.
... The overall estimate from the meta-analysis uncovered that infant death is 0.3560 times or 64.4% less likely in women who undergo antenatal care than those who do not. This result is supported by other studies and shows the significance of primary care for the mother and new-born children [57][58][59]. A conceivable explanation could be women undergoing ANC visits get the opportunity for prompt detection of complications and early inception of breastfeeding, which help increase the resistance of a child [60]. ...
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Article
Background. Infant mortality is a salient indicator for appraising the quality of the healthcare infrastructures of a country. To achieve the sustainable development goal, the infant mortality rate should be reduced to the indicated level. On account of this, it is requisite to point out the associated factors of infant mortality and provide action plans for monitoring them. Objectives. This study aimed to discover the prevalence of infant mortality and assess how different factors influence infant mortality in 24 developing countries by utilising the latest Demographic and Health Survey (DHS) data. Material and methods. This study used a mixed-method design to assemble cross-sectional studies to integrate data from 24 other countries due to the widening perspective of infant mortality. Descriptive analysis, binary logistic regression model, random-effect meta-analysis and forest plot have been used for the analyses. Results. The binary logistic regression model for Bangladesh revealed that a higher education level of fathers (OR: 0.344, 95% CI: 0.147; 0.807), being 2nd born or above order infant (OR: 0.362, 95% CI: 0.248; 0.527), undergoing antenatal care (ANC) (OR: 0.271, 95% CI: 0.192; 0.382 for 1–4 visits) and undergoing postnatal care (PNC) (OR: 0.303, 95% CI: 0.216; 0.425) were statistically significant determinants of lowering infant death. While carrying multiple foetuses (OR: 6.634, 95% CI: 3.247; 13.555) was shown to be a risk factor of infant mortality. The most significant factors influencing infant mortality for developing countries were the number of foetuses (OR: 0.193, 95% CI: 0.176; 0.213), undergoing ANC (OR: 0.356, 95% CI: 0.311; 0.407), undergoing PNC (OR: 0.302, 95% CI: 0.243; 0.375) and the size of the children (OR: 0.653, 95% CI: 0.588; 0.726). Conclusions. In this study, the number of the foetuses, undergoing ANC and PNC, mother’s education, fathers’ education and size of the children were the most significant factors affecting infant mortality in developing countries. Thusly, anticipation and control projects need to be taken considering the outcome of this study to reduce the infant mortality. Key words: infant mortality, prenatal care, developing countries, meta-analysis.
... On the contrary, in high-income countries, antepartum hemorrhage and congenital malformations are the most common causes of stillbirth. 3 Sustainable developmental goal 3 targets ending preventable new born deaths and reduce neonatal mortality to at least 12 per thousand by the year 2030. 7 On similar lines, National Health Policy (NHP) 2017 of India set a target of 23 deaths per 1000 live births for under-5 mortality and 16 deaths per 1000 livebirths for neonatal mortality by 2025. ...
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Article
Perinatal mortality (PM) is a major public health problem in India and multiple maternal and foetal risk factors have been attributed to high perinatal mortality. This review aimed to systematically summarize the epidemiological literature on maternal and fetal risk factors for PM including those for still birth, intrauterine deaths; early neonatal mortality; early neonatal deaths in India. This systematic review was compliant with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We searched for peer-reviewed articles from three electronic bibliographic databases: MEDLINE, Embase, Google Scholar published between 1 January 2000 and 31 March 2019 that reported the risk factors of perinatal mortality in India. Observational studies (cross sectional, case-control and COHORT Studies). Eighteen articles were included in this review. The major risk factors identified for perinatal mortality in India were maternal age, parity, higher birth order and maternal anemia. Complications during pregnancy like ante partum hemorrhage, preeclampsia, obstructed labor, preterm labor and fetal factors like gestational age and low birth weight were documented as risk factors for perinatal deaths. Strengthening national health programs and targeted interventions for both antenatal and institutional care is required to bring down perinatal deaths in India.
... Adequate prenatal care, initiated within the first trimester of pregnancy and increasing in frequency as the delivery date approaches, is associated with a lower risk of prematurity, stillbirth, and neonatal death [34]. Latino pregnant individuals have lower rates of timely initiation of prenatal care, measured by access to care during their first trimester, compared to non-Hispanic whites [35]. For non-US-born Latino pregnant individuals, late prenatal care initiation rates are significantly higher than their US-born counterparts [36][37][38]. ...
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Article
Background Digital mobile health (mHealth) applications are a popular form of prenatal education and care delivery in the U.S.; yet there are few Spanish language options for native speakers. Furthermore, existing applications do not consider cultural differences and disparities in healthcare access, including those specific to emerging Latino communities. Objective To adapt and translate an English-language pregnancy mobile health app to meet the language and cultural needs of Spanish-speaking Latino immigrants living in the United States. Methods We use a multi-step process, grounded in implementation science frameworks, to adapt and translate the contents of an existing pregnancy app. Interviews with stakeholders (n = 12) who advocate for the needs of pregnant individuals in an emerging Latino community were used to identify domains of possible disparities in access to prenatal care. We then conducted semi-structured interviews with peripartum Spanish-speaking Latino users (n = 14) to understand their perspectives within those domains. We identified a list of topics to create educational material for the modified app and implemented a systematic translation approach to ensure that the new version was acceptable for immigrants from different countries in Latin America. Results The interviews with stakeholders revealed seven critical domains that need to be addressed in an adapted prenatal app: language and communication, financial concerns, social support, immigration status, cultural differences, healthcare navigation, and connection to population-specific community resources that offer Spanish language services. The interviews with peripartum Spanish-speaking Latino women informed how the existing content in the app could be adjusted or built upon to address these issues, including providing information on accessing care offered in their native language and community support. Finally, we used a systematic approach to translate the existing application and create new content. Conclusion This work illustrates a process to adapt an mHealth pregnancy app to the needs of an emerging Latino community, by incorporating culturally sensitive Spanish language content while focusing on addressing existing health disparities.
Article
Background The aim of the study, to evaluate the relationship between mode of delivery and preterm morbidities and mortality, who born ≤34 weeks of gestation within 1 year. Materials and methods Babies were divided into two groups as who were born by cesarean section (CS) and vaginal delivery (VD) between March 2019 and March 2020. Infants born at ≤28 weeks were also analyzed. Results The rate of CS delivery was 76% (378) in the whole group and 73% (115) in the babies of ≤28 gestational weeks. The most common maternal factor causing CS was preeclampsia (25%). The antenatal corticosteroid (ACS) application rate was 30% (152) in the whole group and 30% (45) in infants of ≤28 weeks. Rate of babies with an Apgar score of <5 at 5th min, asphyxia, multiple organ failure, development of severe respiratory distress syndrome, severe intraventricular hemorrhage (IVH) and mortality were significantly increased in infants born VD (for all p < 0.05). Mortality was significantly higher when gestational age was ≤28 weeks, birth weight was ≤1500 g and ACS was not administered (p < 0.001 for all). Conclusion Mortality, severe IVH, neonatal asphyxia and multiple organ failure were found to be higher in those who were born by VD. These findings suggest that these results were due to inadequate prenatal care and follow-up and lack of ACS.
Article
Objective All women should have access to adequate and respectful maternal care to maximise health outcomes. In Poland, there is a mismatch between good maternal health indicators and poor care experiences. This study examined stakeholder views on access to adequate maternal care in Poland in terms of availability, appropriateness, affordability, approachability, and acceptability. Design A mixed-methods study. Setting Online survey and online semi-structured interviews conducted between March 2021 and May 2021. Participants Five-hundred fifty-seven (557) women who recently gave birth in Poland, maternal care providers and decision-makers active in the field of maternal health. Findings The main barriers to adequate care were inappropriate communication of maternal care providers, insufficient compliance with standards of care, over-medicalisation of childbirth and suboptimal engagement of women in care provision, and high levels of out-of-pocket spending on maternal care services. Other barriers included limited availability of maternal care providers, particularly midwives, and low reproductive health literacy in women. Key conclusions Provision of adequate and women-centred maternal care remains erratic, despite substantial care provision advancements in recent years. Addressing the barriers could substantially improve the experience of and access to adequate maternal care in Poland. Implications for practice Barriers identified in the survey with women largely converged with those highlighted in the interviews. In addition, maternal care providers and decision-makers provided context-specific information and explanation of the current state of maternal care system. Consequently, this study provides direction-setting information for policy and practice in Poland and other Central and Eastern European countries, which share similar shortcomings related to adequate maternal care provision.
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Background: The coronavirus disease 2019 (COVID-19) pandemic was accompanied by new challenges for psychosocial health care to enable the support of affected patients, their families, and staff in general hospitals. In this study, we aimed to describe the structures and procedures put in place by psychosomatic, psychiatric, and psychological consultation and liaison (CL) services in German, Austrian, and Swiss general hospitals, and to elucidate the emerging needs for cooperation, networking, and improvement. Methods: We conducted a cross-sectional online survey between December 2020 and May 2021, using a 25-item questionnaire derived from relevant literature, professional experience, and consultation with the participating professional societies. The survey was disseminated via national professional societies, relevant working and interest groups, and heads of the above-mentioned CL services. Results: We included responses from 98 CL services in the analyses, with a total response rate of 55% of surveyed hospital CL services; 52 responses originated from Germany, 20 from Austria, and 26 from Switzerland. A total of 77 (79%) of the 98 responding CL services reported that “COVID-19-related psychosocial care” (COVID-psyCare) was provided in their hospital. Among these, 47 CL services (61%) indicated that specific cooperation structures for COVID-psyCare had been established within the hospital. A total of 26 CL services (34%) reported providing specific COVID-psyCare for patients, 19 (25%) for relatives, and 46 (60%) for staff, with 61, 12, and 27% of time resources invested for these target groups, respectively. Regarding emerging needs, 37 (48%) CL services expressed wishes for mutual exchange and support regarding COVID-psyCare, and 39 (51%) suggested future changes or improvements that they considered essential. Conclusion: More than three-quarters of the participating CL services provided COVID-psyCare for patients, their relatives, or staff. The high prevalence of COVID-psyCare services targeting hospital staff emphasizes the liaison function of CL services and indicates the increased psychosocial strain on health care personnel during the COVID-19 pandemic. Future development of COVID-psyCare warrants intensified intra- and interinstitutional exchange and support. Trial Registration: ClinicalTrials.gov NCT04753242, version 11 February 2021.
Article
Background The United States has persistently high rates of preterm birth and low birthweight, and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, like CenteringPregnancy, have been proposed as a potential approach to improve rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes. Objectives This study aimed to test whether participation in group prenatal care would reduce rates of preterm birth and low birthweight compared to individual prenatal care, and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients. Study Design This is a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and then randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth <37 weeks gestational age and low birthweight <2500 grams. The primary analysis was performed according to the intent-to-treat principle. Secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per compliance approaches. Analysis of effect modification by race and ethnicity was planned. Results A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 (40.5%) Black, 502 (21.4%) Hispanic, 863 (36.8%) White, and 31 (1.3%) “Other race or ethnicity”. Group prenatal care did not reduce the rate of preterm birth (10.4% vs. 8.7%, OR 1.22, 95% CI 0.92–1.63, p=0.17) or low birthweight (9.6% vs. 8.9%, OR 1.08, 95% CI 0.80–1.45, p=0.62) when compared to individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most pronounced for rates of low birthweight for Black participants in group care; intent-to treat 12.5% (51/409), modified intent-to-treat 11.5% (36/313), and per compliance 8.3% (20/240). While LBW rates were significantly higher for Black participants compared to White participants seen in individual care (aOR 2.00, 95% CI 1.14 – 3.50) the difference was not significant for Black participants in group care compared to their White counterparts (aOR 1.58, 95% CI 0.74 – 3.34). Conclusions There was no significant difference in overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, we observed lower rates of preterm birth and low birthweight for Black participants. The role for group care models in reducing racial disparities in these birth outcomes requires further study.
Article
Six hundred and six low income women were studied postpartum to assess the relationship among medical risk factors, use or alcohol and drugs, race, content/amount or prenatal care and birth weight. Content of prenatal care was defined by the number of medical procedures performed and amount of care was determined by the Kessner Index. Women received prenatal care in 1-4 different sites. Those remaining in or transferring to sites performing the least number of routine prenatal procedures delivered babies with lower birth weights than those selecting sites performing more procedures. A path analysis (LISREL) constructed a priori to model the relationships among medical risk factors, use of alcohol and drugs, race, content/amount of prenatal care received and birth weight, revealed that women at high medical risk were more likely to receive care at sites offering more medical procedures while those who abused drugs and alcohol were significantly less likely to receive care. Medical risk factors and the use of alcohol and drugs had significant negative effects on birth weight, while content and amount of prenatal care contributed to improved birth weight. These findings are discussed relative to issues of access to high quality prenatal care by patients at greatest risk and to the prevention of low birth weight infants.
Article
Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.
Article
The aim of this study was to determine whether inadequate prenatal care is associated with increased risk of preterm birth among adolescents. We selected a random sample of women under age 20 years with singleton pregnancies delivering in Washington State between 1995 and 2006. Multivariate logistic regression was used to assess the association between prenatal care adequacy (percent of expected visits attended, adjusted for gestational age) and preterm birth. Of 30,000 subjects, 27,107 (90%) had complete data. Women without prenatal care had more than 7-fold higher risk of preterm birth (n = 84 [24.1%]; adjusted odds ratio [aOR], 7.4), compared with those attending 75-100% of recommended visits (n = 346 [3.9%]). Women with less than 25%, 25-49%, or 50-74% of expected prenatal visits were at significantly increased risk of preterm birth; risk decreased linearly as prenatal care increased (n = 60 [9.5%], 132 (5.9%], 288 [5%]; and aOR, 2.5, 1.5, and 1.3, respectively). Inadequate prenatal care is strongly associated with preterm birth among adolescents.
Article
Several different indices of prenatal care have been used in birth outcome models to analyze the relationship between the adequacy of prenatal care and low birthweight, preterm birth, and infant mortality. This investigation compared the performance of the Kessner index, the GINDEX, the adequacy of prenatal care utilization (APNCU) and certain variants of the APNCU in such outcome models. Data from National Center for Health Statistics' (NCHS) Linked Birth and Infant Death Cohort files were used in multivariate logistic regression models to estimate adjusted odds ratios comparing different prenatal care utilization categories for each index. When the indices were used in small-for-gestational-age outcome models, the conclusions suggested by the various indices were similar. In models for preterm birth and infant mortality, by contrast, the various indices gave widely differing results. Unlike the use of other indices, the use of the GINDEX paradoxically suggested that birth outcomes were better in the inadequate, intermediate, and intensive categories than in the adequate category. The conclusions drawn concerning the association between prenatal care utilization and small-for-gestational-age seem relatively robust in the sense of being consistent across indices. In analyzing associations between prenatal care and preterm birth or infant mortality, care must be taken in choosing indices, because results differ substantially across indices.
Article
Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive inadequate or less than adequate care. The study reported here examined the predictive power of a set of variables describing the type of financial coverage available to the mother, attributes of the mother, father and family and characteristics of the health care system. A stratified random sample of mothers was generated from state birth certificate files and surveyed through the use of a mailed questionnaire. Stratification was designed to assure adequate representation of subgroups expected to receive less adequate prenatal care. The study findings indicate that there were deficiencies in prenatal care utilization and that these deficiencies were concentrated in specific areas and subpopulations within the state. While the majority of women in the study started prenatal care in the recommended first trimester, most did not maintain the recommended schedule of visits with their care provider. The following conditions were found to reduce the likelihood of receiving adequate care after controlling for service need: younger women (particularly adolescents); less educated (particularly those without a high school education); low income; longer travel time; Medicaid recipient; and rural resident. In addition, it was found that where one lives is a significant predictor of the adequacy of prenatal care even after controlling for all of the above variables. The authors conclude that it is important in assessing potential policy and program options for reducing differentials in prenatal care use to distinguish between economic and noneconomic barriers to utilization. Receipt of Medicaid does not assure adequate prenatal care use.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Black infants are born with low birth weights (< 2500 g) and very low birth weights (< 1500 g) at twice the rate of white infants. We investigated the effect of prenatal care delivered in a health maintenance organization on the birth weights of black and white infants at normal risk for low birth weight. Using birth certificates for all children born in 1978 in the California Kaiser-Permanente hospitals, we studied data on more than 31,000 black and white newborns whose mothers' ages and levels of education were comparable. The data show that black mothers used prenatal care less extensively and had a higher incidence of infants with low birth weights (8.4 vs 3.6 percent) and very low birth weights (2.0 vs 0.7 percent) than white mothers. The difference in the use of prenatal care, however, accounted for less than 15 percent of the difference in the incidence of low birth weight. The rates of low birth weight, very low birth weight, and preterm birth (< 260 days' gestation) decreased with increasing levels of prenatal care for both blacks and whites. However, increasing levels of care were associated with a greater reduction among black infants than among white infants in low birth weight, very low birth weight, and low birth weight at term (≥ 260 days' gestation). When we compared mothers who received adequate care with those who received inadequate care, the relative risk of giving birth to a very-low-birth-weight infant was reduced 3.6-fold (95 percent confidence interval, 2.0 to 6.6) for black mothers and 2.1-fold (confidence interval, 1.3 to 3.4) for white mothers; the relative risk of giving birth to a low-birth-weight infant at term was reduced 3.4-fold (95 percent confidence interval, 2.2 to 5.4) for black mothers and 1.6-fold (confidence interval, 1.1 to 2.3) for white mothers. We conclude that even in a population of women at low risk for giving birth to low-birth-weight infants, prenatal care is more beneficial for blacks than for whites.
Article
It is generally recognized that low birth weight can be caused by many factors. Because many questions remain, however, about which factors exert independent causal effects, as well as magnitude of these effects, a critical assessment and meta-analysis of the English and French language medical literature published from 1970 to 1984 were carried out. The assessment was restricted to singleton pregnacies of women who lived at sea level and who had no chronic illnesses. Extremely rare factors were also excluded, as were complications of pregnancy. In this way, 43 potential determinants were identified. A set of a priori methodological standards were established for each potential determinant. Studies that satisfactorily met (SM) or partially met (PM) these standards were used to assess the existence and magnitude of an independent causal effect on birth weight, gestational age, prematurity, and intrauterine growth retardation (IUGR). A total of 921 relevant publications were identified, of whihc 895 were successfully located and reviewed. Factors with well-established direct causal impacts on intrauterine growth include infant sex, racial/ethnic origin, maternal height, pre-pregnancy weight, paternal weight and height, maternal birth weight, parity, history or prior low-birth-weight infants, gestational weight gain and caloric intake, general morbidity and episodic illness, malaria, cigarette smoking, alcohol consumption, and tobacco chewing. In developing countries, the major determinants of IUGR are Black or Indian racial origin, poor gestational nutrition, low pre-pregnancy weight, short maternal stature, and malaria. In developed countries, the most important single factor, by far, is cigarette smoking, followed by poor gestational nutrition and low pre-pregnancy weight. For gestational duration, only pre-pregnancy weight, prior history of premature or spontaneous abortion, in utero exposure to diethylstilbestrol, and cigarette smoking have well-established causal effects, and the majority of prematurity occurring in both developing and developed country settings remains unexplained. Modifiable factors with large effects on intrauterine growth or gestational duration should be targeted for public health intervention in the two settings, with an emphasis on IUGR in developing countries and prematurity in developed countries. Future research should focus on factors of potential quantitative importance for which data are either unavailable or inconclusive. In developing countries, the most important of these for intrauterine growth are caloric expenditure (maternal work), antenatal care, and certain vitamins and trace elements. For prematurity, especially in developed countries, factors deserving further study include genital tract infection, antenatal care, maternal employment and physical activity, and stress and anxiety.
Article
This study proposes a redesigned measure of prenatal care utilization based on modifications made to a preexisting index of the adequacy of such care. Six prenatal care utilization groups were delineated: intensive, adequate, intermediate, inadequate, no-care, and missing/unknown. Using 430,349 cases from South Carolina and North Carolina vital records from 1978 to 1982 (live birth-infant death cohort files for white resident mothers), this proposed prenatal care utilization measure was examined by maternal sociomedical risk characteristics (age-parity, marital status, education, complications of pregnancy, and previous pregnancy terminations) and by pregnancy outcomes (birth weight, gestational age, and birth weight- and gestational age-specific neonatal mortality). The intensive prenatal care group had relatively more pregnancy complications but also the most preferred pregnancy outcomes. Appreciable differences in birth weight and gestational age distributions were observed among the prenatal care categories within maternal risk status groups. Increased utilization of prenatal care was associated with higher mean birth weight and gestational age. However, after controlling for maternal risk status, an appreciable variation in birth weight- and gestational age-specific neonatal mortality was not apparent across prenatal care groups.