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In the course of prenatal care, the sera from 5670 pregnant women were investigated. The average infection rate in the population was 39.22%; 60.39% were seronegative. To minimise the risk involved in toxoplasmosis infection, toxoplasma-antibodies must be definitely determined during prenatal care. This should be carried out simultaneously with the determination of antibodies to the rubella virus.
OBJECTIVE: To evaluate evidence that prenatal care improves birth outcomes. DATA SOURCES: The MEDLINE data base was searched for appropriate studies for the years 1966-1994; a review of published studies was also conducted. METHODS OF STUDY SELECTION: Published observational and experimental studies of prenatal care that met specified criteria were selected. DATA EXTRACTION AND SYNTHESIS: Studies were graded based on the system used by the United States Preventive Services Task Force. Data were assessed using established criteria for the evaluation of prenatal interventions: temporal relationship, biologic plausibility, consistency, alternative explanations, dose-response, strength of association, and cessation effects. Current evidence did not satisfy the criteria. CONCLUSION: Prenatal care has not been demonstrated to improve birth outcomes conclusively. However, policymakers deciding on funding for prenatal care must consider these findings in the context of prenatal care's overall benefits and potential cost-effectiveness. Cost-effective reductions in low birth weight deliveries may be beyond the statistical powers of detection of current studies.
The Minnesota Prenatal Care Coordination Project was a statewide effort to present systematically education and technical support to providers as they implemented the Minnesota Prenatal Care Initiative for expanded services to high-risk women. Educational methods included holding 12 regional workshops throughout the State, one-to-one contacts by nurse consultants, and newsletters and a guidebook (manual) were distributed to reach community providers. Analysis of the implementation was conducted using site visits, interviews with providers, and reviews of medical records, claims data, and other project documents. Successes in the first year were a twofold increase in the numbers of Medicaid-enrolled women who received risk assessment and enhanced services, more than one-third increase in provider participation, greater collaboration among multidisciplinary providers at the community level, and improved communication between State and local health care agencies. Obstacles included provider resistance to changes in practice, dissatisfaction with the enhanced services package and level of reimbursement, and problems with implementation protocols. The project demonstrated that prenatal care providers will change; they will improve practices and collaboration as a result of personalized education and support.
OBJECTIVES: To examine the association between adverse infant outcomes and maternal under utilization of prenatal care, among women delivering at Harare Maternity Hospital. DESIGN: Hospital based, cross sectional study. SETTING: Harare Maternity Hospital, Harare, Zimbabwe. SUBJECTS: A random sample of 3,864 pregnant women. MAIN OUTCOME MEASURES: Prenatal care utilization, maternal socio-demographic information, as well as birth weight and other neonatal outcome characteristics. RESULTS: Of the total number of women who participated in this study 3,491 (90%) had at least one prenatal care visit. Women receiving no prenatal care, were more likely to be younger, unmarried and to have been transferred for delivery as compared with women receiving prenatal care. Women receiving no prenatal care were seven times more likely to deliver an infant weighing less than 1,500 grams, adjusted odd ratio (OR) = 7.22; 95% confidence interval (CI) 4.58 to 11.39 as compared with those who booked for care. Newborns of unbooked mothers were more likely to have a low apgar score at birth, adjusted OR = 1.71; to have been admitted to the neonatal intensive care unit, adjusted OR = 2.14, and to require intubation, adjusted OR = 3.35. A large proportion of women (31.4%) initiated prenatal care after 30 weeks gestation. CONCLUSIONS: There were significant differences between maternal characteristics and foetal outcomes in relation to booking status. Under utilization of prenatal care was associated with sub-optimal foetal outcomes. Improving the socio-economic status of women, their education and access to health care, and family planning methods are all strategies that should contribute to the reduction of adverse foetal outcomes.
OBJECTIVE: This article reports on analysis of the predisposing and enabling factors that affect black/white differences in utilization of prenatal care services. DATA SOURCES: We use a secondary data source from a survey conducted by the Michigan Department of Public Health. STUDY DESIGN: The study uses multivariate analysis methods to examine black/white differences in (1) total number of prenatal care visits, (2) timing of start of prenatal care, and (3) adequacy of care received. We use the model advanced by Aday, Andersen, and Fleming (1980) to examine the effect of enabling and predisposing factors on black/white differences in prenatal care utilization. DATA COLLECTION: A questionnaire was administered to all women who delivered in Michigan hospitals with an obstetrical unit. PRINCIPAL FINDINGS: Enabling factors fully accounted for black/white differences in timing of start of prenatal care; however, the model could not fully account for black/white differences in the total number or the adequacy of prenatal care received. CONCLUSION: Although there are no black/white differences in the initiation of prenatal care, black women are still less likely to receive adequate care as measured by the Kessner index, or to have as many total prenatal care contacts as white women. It is possible that barriers within the health care system that could not be assessed in this study may account for the differences we observed. Future research should consider the characteristics of the health care system that may account for the unwillingness or inability of black women to continue to receive care once they initiate prenatal care.
OBJECTIVE: To evaluate variations in prenatal care quality by public and private clinical settings and by household wealth. DESIGN: The study uses 2003 data detailing retrospective reports of 12 prenatal care procedures received that correspond to clinical guidelines. The 12 procedures are summed up, and prenatal care quality is described as the average procedures received by clinical setting, provider qualifications, and household wealth. SETTING: Low-income communities in 17 states in urban Mexico. PARTICIPANTS: A total of 1253 women of reproductive age who received prenatal care within 1 year of the survey. MAIN OUTCOME MEASURE: The mean of the 12 prenatal care procedures received, reported as unadjusted and adjusted for individual, household, and community characteristics. RESULTS: Women received significantly more procedures in public clinical settings [80.7, 95% confidence interval (CI) = 79.3-82.1; P < or = 0.05] compared with private (60.2, 95% CI = 57.8-62.7; P < or = 0.05). Within private clinical settings, an increase in household wealth is associated with an increase in procedures received. Care from medical doctors is associated with significantly more procedures (78.8, 95% CI = 77.5-80.1; P < or = 0.05) compared with non-medical doctors (50.3, 95% CI = 46.7-53.9; P < or = 0.05). These differences are independent of individual, household, and community characteristics that affect health-seeking behavior. CONCLUSIONS: Significant differences in prenatal care quality exist across clinical settings, provider qualifications, and household wealth in urban Mexico. Strategies to improve quality include quality reporting, training, accreditation, regulation, and franchising.
OBJECTIVES: Prenatal care is an established mechanism for identifying and managing risk factors impacting pregnancy outcomes. Despite aggressive efforts in the United States (US) to assure that all women begin care in the first trimester, every year about 70,000 women in the US receive no care prior to delivery. We hypothesized that US women receiving no prenatal care comprise clusters (subgroups) with distinctive behavioral, socio-demographic, and medical risks and that birth outcomes differ among the clusters. METHODS: White, Black, and Hispanic women (n = 126,220) receiving no prenatal care and delivering a live, singleton infant were identified from linked birth and death certificates for years 1995 through 1997. Cluster analysis was used to group women with similar characteristics, and cluster assignment was evaluated using discriminant analysis. Birth outcomes for any care and no-care women were then examined using logistic regression. RESULTS: Six replicable clusters of women with no care were identified. Birth outcomes varied significantly among clusters and were two to four times worse for no-care clusters compared to outcomes for women receiving any care. CONCLUSIONS: Cluster analysis is an effective alternative for grouping individuals for use in public health education, intervention, and outreach programming. Women receiving no prenatal care were characteristically different from women receiving any care in this study, but they did not represent a homogenous group. Findings suggest that interventions should target reducing the proportion of women receiving no care and should be tailored to specific no-care clusters.
BACKGROUND: Recent expansions in eligibility for coverage of prenatal care services by the Medicaid program reflect national initiatives to improve pregnancy outcomes. This study investigates the potential impact that completeness of reporting of prenatal care and gestational age variables and strategies to impute missing data may have on evaluations of the Medicaid expansion. METHODS: This study, examining 15 years of vital record data from a single state and comparing 1 year of data from four mid-Atlantic states, selected single live births to resident mothers for analyses. The "day 15" and the "preceding case" methods were used to impute missing gestational age data. RESULTS: Considerable temporal and geographic variation was detected in completeness of reporting of variables used to construct prenatal care indices. After imputing values for cases with missing data, the proportion of cases for which adequacy of prenatal care utilization could not be determined ranged from 3% to 24% among the states investigated. For those cases where gestational age data could be imputed, the distribution of prenatal care utilization was not markedly disparate from those cases with complete reporting of gestational age. CONCLUSIONS: The results indicate that variations in reporting, decisions regarding the treatment of missing data, and the choice of the denominator can alter prenatal care utilization percentages and have implications for evaluations of the impact of the recent Medicaid expansion on prenatal care utilization.
STUDY OBJECTIVE: To determine if there is a high seroprevalence of syphilis in pregnant women without prenatal care presenting to an urban emergency department. DESIGN: Prospective, nonblinded sampling of pregnant women without prenatal care with a comparison group of pregnant women with prenatal care from the obstetrics clinic. Patients in the ED setting were asked about such associated risk factors as previous syphilis and drug use. SETTING: Urban ED. TYPE OF PARTICIPANTS: Pregnant women without prenatal care. INTERVENTION: Patients were screened for syphilis using the automated reagin test. Reactive automated reagin tests were confirmed by the fluorescent treponemal antibody absorption. In addition, 44 patients with nonreactive automated reagin tests had confirmatory tests done. New cases were verified by the state health department. MEASUREMENTS AND MAIN RESULTS: Seventy-two patients were included in the study. The average age was 25 years. Eight patients (11.1%) were diagnosed with previously undetected syphilis. Four patients (5.6%) had previously treated syphilis. The laboratory cost of screening was $248 per new case of syphilis detected. The study group was compared with 118 patients matched for age and race who presented to the obstetrics clinic for routine prenatal care. Two new cases of syphilis were discovered in the clinic population (1.7%). CONCLUSION: A high rate of syphilis infection was detected in this inner-city ED population presenting without prenatal care. This was higher than that found in the patients presenting for obstetrics care in the clinic. Patients can be screened effectively in the ED.
This research attempts to close an important gap in health economics regarding the efficacy of prenatal care and policies designed to improve access to that care, such as Medicaid. We argue that a key beneficiary-- the mother-- has been left completely out of the analysis. If prenatal care significantly improves the health of the mother, then concluding that prenatal care is 'ineffective' or that the Medicaid expansions are a 'failure' is premature. This paper seeks to rectify the oversight by estimating the impact of prenatal care on maternal health and the associated cost savings. We first set up a joint maternal-infant health production framework that informs our empirical analysis. Using data from the National Maternal and Infant Health Survey, we estimate the effects of prenatal care on several different measures of maternal health such as body weight status and excessive hospitalizations. Our results suggest that receiving timely and adequate prenatal care may increase the probability of maintaining a healthy weight after the birth and, perhaps for blacks, of avoiding a lengthy hospitalization after the delivery. Given the costs to society of obesity and hospitalization, these are benefits worth exploring before making conclusions about the effectiveness of prenatal care-- and Medicaid.
OBJECTIVES: The objectives of this study are to examine the influence of paternal and maternal education and marital status on the initiation and adequate use of prenatal care services. METHODS: Data were obtained from the 1990-1991 Minnesota Live Birth file. Single live births to white resident mothers who were 21 years of age or older were selected for investigation. After these selections 102,798 cases were analyzed. RESULTS: Logistic regression was used to examine the association of parental characteristics on the following three measures of poor prenatal care use: (1) receiving no prenatal care; (2) initiating care later than the first trimester; and (3) given a first trimester start of care, receiving less than the recommended number of prenatal care visits. Within each maternal education stratum, an increased risk of delayed initiation and less efficient use of prenatal care were observed for lower paternal educational attainment. Unmarried women, regardless of educational level, exhibited more than a tenfold risk of receiving no prenatal care, and unmarried women of low educational attainment exhibited the highest risk of delayed care. CONCLUSIONS: A persistent positive effect of increasing paternal education on the level of adequacy of prenatal care utilization within all maternal marital status and educational attainment groups poses further challenges to our understanding of the factors that influence prenatal care use.
OBJECTIVES: We examined trends and racial disparities (White, African American) in trimester of prenatal care initiation and adequacy of prenatal care utilization for US women and specific high-risk subgroups, e.g., unmarried, young, or less-educated mothers. METHODS: Data from 1981-1998 US natality files on singleton live births to US resident mothers were examined. RESULTS: Overall, early and adequate use of care improved for both racial groups, and racial disparities in prenatal care use have been markedly reduced, except for some young mothers. CONCLUSIONS: While improvements are evident, it is doubtful that the Healthy People 2000 objective for prenatal care will soon be attained for African Americans or Whites. Further efforts are needed to understand influences on and to address barriers to prenatal care.
This paper considers policy and programmatic consequences of shifting measurement of prenatal care utilization from the Kessner Index (KI) to the Adequacy of Prenatal Care Utilization Index (APNCUI). In gauging the adequacy of prenatal care utilization, the KI considers the timing of prenatal care initiation and the number of prenatal visits. The APNCUI also considers both timing of initiation and number of visits, but the approach taken to conceptualizing and measuring these two aspects of prenatal care utilization is more refined. We used birth certificates to calculate the KI and the APNGUI for 217,183 New York City (NYC) births in 1991-1992. We used cross-tabulations and bivariate odds ratios to compare the classifications resulting from the respective indexes. The APNCUI detected some important dimensions of the problem of inadequate prenatal care use that are not evident when using the KI. The proportion of births with inadequate use increases from 18% with the KI to 35% with the APNGUI. Groups of women at elevated risk for inadequate use are the same, but the KI understates significantly the risk for Hispanic women, teens, women who are less well educated, and those on WIC and Medicaid. The APNGUI yields a fuller picture of the degree to which some urban women are at risk for inadequate prenatal care use. Use of the APNGUI in quality assurance, monitoring, and research is recommended.
Many municipalities provide special prenatal care services targeted to low-income women whose access to prenatal care is constrained. For such services to be successful and effective, they must be geographically targeted to the places where low-income, high-need mothers live. This paper presents a GIS analysis of prenatal care need and clinic services for low-income mothers in Brooklyn, NY. We analyze fine-grained geographic variation in need using data on the residential locations of recent mothers who lack health insurance or are covered by Medicaid. Spatial statistical methods are used to create spatially smoothed maps of the density of mothers and corresponding maps of the density of prenatal clinics. For these mothers, clinic density is positively associated with early initiation of prenatal care. Although clinic locations conform relatively well to the residential concentrations of high-need women, we identify several underserved areas with large numbers of needy women and few clinics available.
PURPOSE: Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored. METHODS: We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy. RESULTS: Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care. CONCLUSION: Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.
OBJECTIVES: We sought to describe prenatal care use in the United States and in three European countries where accessibility to prenatal care has been reported to be better than it is in the United States. METHODS: We analyzed the 1980 US National Natality Survey, the 1981 French National Natality Survey, a 1979 sample of Danish births, and a survey performed from 1979 to 1980 in one Belgian province. RESULTS: The proportion of women who began prenatal care late (after 15 weeks) is highest in the United States (21.2%) and lowest in France (4.0%). This contrasts with the median number of visits, which is greater in the United States (11) than in Denmark (10) or in France (7). Across all maternal ages, parities, and educational levels, late initiation of prenatal care is more frequent in the United States, and median number of visits in the United States is equal to or higher than that in the other countries. CONCLUSIONS: In countries that offer nearly universal access to prenatal care, women begin care earlier during pregnancy and have fewer visits than women in the United States.
BACKGROUND: Prenatal care provides an opportunity for counseling about behaviors and experiences that increase the likelihood of adverse maternal and fetal outcomes. OBJECTIVE: To document (1) prevalence of preventive health counseling during prenatal care, (2) prevalence of women in higher need of counseling about specific health concerns, and (3) whether women in higher need for counseling were more likely than women in lower need to have received counseling. METHODS: Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS), a state-specific, population-based, random sample of postpartum women, was performed by using data from 14 states for births during 1997 or 1998, for a total of 24,620 participants. Outcome measures included report of preventive health counseling during prenatal visits by specific topic as well as behaviors and experiences about cigarette use, alcohol use, breast-feeding, partner violence, and preterm labor. RESULTS: The percentage of women that report preventive counseling during prenatal care is relatively high (> or =75%) for 9 of 13 topics. However, the percentage of women that report counseling is relatively low (<75%) for partner violence, seat belt use, illegal drug use, and human immunodeficiency virus (HIV) risk. Except for counseling about cigarette and alcohol use, women in higher need, compared with women in lower need, for three other health topics were not significantly more likely to receive counseling. CONCLUSIONS: Preventive health counseling for partner violence, seat-belt use, illegal drug use, and risk of HIV could be increased across prenatal settings. Counseling should involve assessment of risks, with focused counseling related to those risks.
We sought to estimate the impact of maternal HIV testing and prenatal care on the potential to reduce vertical transmission through zidovudine (AZT) use by HIV-infected mothers. We evaluated the prepartum maternal HIV diagnosis rate, prenatal care, disease stage, and vertical transmission rate (from a two-part mixture model) using New York State Medicaid and vital statistics data for HIV-infected mothers and their singletons in 1985-90. We used published data to estimate the effect of AZT on vertical transmission and expert input to define other parameters for the model. Our HIV-infected (N = 1514) had a vertical transmission rate of 27.0%. HIV was diagnosed prepartum for 39.5% of women in 1990. Transmission would have been 22.2% if AZT had been taken only by the subset of women diagnosed prepartum with HIV and receiving prenatal care by 34 weeks gestation (86.7%). Transmission would have dropped to 11.2% if all women had been diagnosed prepartum with HIV and received adequate prenatal care. The observed deficiencies in prenatal care and maternal HIV diagnosis rates in this Medicaid population-based cohort must be addressed to realize the promise of AZT to reduce vertical transmission.