Terminology and Measures

No single specification of the content of prenatal care is unanimously accepted by public health authorities, health care providers, or researchers. The American College of Obstetricians and Gynecologists (ACOG) and a joint working group of representatives from ACOG and from the American Academy of Pediatrics have discussed the goals and content of prenatal care in some detail,^1,2 however, and the Expert Panel on the Content of Prenatal Care and the Preventive Services Task Force (both housed within the U.S. Department of Health and Human Services) promise additional guidance in the future. In the absence of an agreement on the content of prenatal care and because many of its components are difficult to measure, most research on the effectiveness of prenatal services focuses on quantity of care received (such as number of prenatal visits).

Prenatal care differs from other types of health care in the measures used to understand its impact on health outcomes. Most studies of the effectiveness of medical care examine provider actions—for example, did the physician take an adequate history, order the appropriate tests, and conduct the right procedures? By contrast, studies of the role of prenatal care in pregnancy outcome usually examine consumer actions—for example, did the pregnant woman initiate care early, and how many visits did she make? It is unclear why in the field of prenatal services the emphasis is on consumer rather than provider behavior. Exceptions to this method of measuring prenatal care include the work of Morehead, Donaldson, and Seravalli in 1971³ and, more recently, Hughey in 1986.⁴ It is also important to note that various efforts to lower maternal mortality in past years have focused on provider behavior during the prenatal period.

Three measures of the quantity of prenatal care are widely used: (1) the number of visits made throughout pregnancy (frequency), (2) the trimester or month in which care began (timing), and (3) an index relating the frequency and timing of visits to gestational age. This last measure is the basis of the widely used Kessner index,⁵ in which a woman's prenatal care is classified as "adequate" if it begins in the first trimester and includes nine or more visits for a pregnancy of 36 or more weeks; "intermediate" if it begins in the second trimester or includes five to eight visits for a pregnancy of 36 or more weeks; or "inadequate" if it begins in the third trimester or includes four or fewer visits for a pregnancy of 34 or more weeks.

All three of these measures tacitly acknowledge the schedule of prenatal visits recommended by ACOG: care beginning as early in the first trimester of pregnancy as possible, with additional visits every 4 weeks for the first 28 weeks of pregnancy, every 2 to 3 weeks for the next 8 weeks, and weekly thereafter until delivery. Such a schedule yields about 12 visits for a 39-week pregnancy, 13 for a 40-week pregnancy, and 14 for a 41-week pregnancy.

All three measures have two major limitations. First, none includes a precise definition of a prenatal visit. A visit for a pregnancy test only, for example, should not be equated with a prenatal care visit, but anecdotal reports suggest that these two distinct events can be confused by women themselves and commingled in data on use of prenatal care. Second, the measures depend either on a woman's recollection of her prenatal visits or on data contained in her medical record. Both sources can be flawed. For example, if a woman changes her source of care during pregnancy, only the date when she started care at the site used immediately before delivery may be noted in her medical records. If these same records are used to complete the birth certificate—the source of data on which most research in this area is based—earlier prenatal visits will be ignored.

The questionable accuracy of birth certificates is substantiated by a study of the 1972 National Natality Survey, in which the number of prenatal visits listed on birth certificates was compared with survey data. Perfect agreement was found in only 16 percent of the cases.⁶ In another study, Land and Vaughan reviewed Missouri birth certificate data for 1980 and found that hospitals that obtained information on prenatal care exclusively from the mother reported earlier prenatal care and more visits than those using the prenatal record only or a combination of the prenatal record and information from the mother.⁷ Another limitation of birth certificate data is that not all states request information about ethnic origin or the mother's marital status.^* Despite such problems, birth certificates remain the best generally available source of data on participation in prenatal care. In particular, they can be used to compare patterns of use across states and populations, and they facilitate analysis of trends.

Each of the three measures also has unique limitations. Counting the number of prenatal visits, while appealing in its simplicity, ignores the distribution of those visits over the pregnancy. The recommended ACOG schedule speaks as much to the timing of prenatal visits as to their absolute number. In particular, counting visits obscures the relationship between prenatal care and preterm delivery. Even if they follow the recommended prenatal schedule, women who deliver prematurely will obviously have fewer prenatal visits than women who deliver at full term. Unless a statistical adjustment is made for length of gestation, the association of preterm delivery with fewer prenatal visits may appear causal, when, in fact, it probably is not.

The second measure, based on the reported date of the first prenatal visit, emphasizes the recommendation that care should begin ''early,'' in the first trimester of pregnancy. Generally, care beginning in the second trimester is referred to as "delayed," and care deferred until the last trimester is termed "late." Although this measure overcomes some of the problems that the frequency index presents, it does not address the fact that early care does not necessarily mean continuous care. For example, a woman may register early in pregnancy to help arrange hospitalization for delivery but not appear again until the third trimester. Despite this shortcoming, the time-of-onset measure is commonly used because the data needed to compute it are widely available.

The third method, primarily the Kessner index, provides a more precise, multidimensional measure of prenatal care; however, it is complicated to compute, and for many births data are lacking on one or more of the three variables that make up the index (month in which prenatal care was begun, number of visits, and gestational age). A number of modified versions of the Kessner index have been proposed, including one by Kotelchuck.⁸

The measure used most often in this volume is the trimester in which prenatal care was begun, using the terms "early, delayed, and late," as just defined. The terms "adequate, intermediate, and inadequate" are Kessner index phrases, also defined above. The term "insufficient" is used as a general description of care that is neither adequate nor initiated early in pregnancy; similarly, ''sufficient" is used as a general label to describe care that begins early in pregnancy and is sustained until delivery.

A final point: Where vital statistics data are used in this chapter, the data technically refer to infants rather than mothers, because each record is based on an individual birth certificate. However, since multiple births are relatively infrequent (21 per 1,000 live births in 1985) and few women have more than one birth in any year, the terms "women," "mothers," and "births" are often used interchangeably.

Current Patterns of Use^*

According to 1985 birth certificate data for the 50 states and the District of Columbia, 76.2 percent of all infants were born to women who obtained early prenatal care, 18.1 percent to women who delayed care, 4.0 percent to women who obtained care late, and 1.7 percent to mothers who had no prenatal care at all (Table 1.1). In absolute numbers, of the approximately 3.8 million babies born in the United States in 1985, about 2.8 million were born to women who began prenatal care early in pregnancy, about 663,000 to women who delayed care, some 150,000 to women who obtained care late, and about 61,000 to women who had no prenatal care at all (Table 1.2).

TABLE 1.1

Month of Pregnancy in Which Prenatal Care Was Begun (Percent), by Age and Race, United States, 1985.

TABLE 1.2

Month of Pregnancy in Which Prenatal Care Was Begun (Number), by Age and Race, United States, 1985.

When vital statistics are analyzed to determine rates of adequate care rather than trimester of onset, a slightly different picture emerges. Hughes et al. found that in 1985 only 68.2 percent of all women obtained adequate care, 23.9 percent had an intermediate level of care, and 7.9 percent of all women had inadequate care.9

The following sections describe women's use of prenatal care as measured by six sociodemographic factors: race or ethnic origin, age, education, birth order, marital status, and income.

Racial and Ethnic Subgroups

Racial disparities in the use of prenatal care are substantial (Table 1.1). In 1985, black women were far less likely than white women to begin care early and twice as likely to receive late or no care. In absolute numbers, almost 140,000 white infants and almost 60,000 black infants were born to women who had late or no prenatal care (Table 1.2). The higher rates of late or no care among black women are probably due to the greater concentration in this population of several risk factors associated with insufficient prenatal care: limited education, being unmarried (in 1985, 11 percent of white births were to unmarried women versus 57 percent of black births), and, in particular, poverty.

Use of prenatal care by mothers of Hispanic origin has been analyzed for the District of Columbia and the 23 states that routinely collect information on Hispanic births. More than 92 percent of the total U.S. Hispanic population lived in these jurisdictions in 1985, and over 370,000 births to mothers of Hispanic origin were reported. Of these births, the vast majority (95 percent) were listed as being of white race on the birth certificate, two-thirds were to women of Mexican origin, and nearly half (47 percent) were to mothers who had been born in the United States.¹⁰

Generally, Hispanic mothers are substantially less likely than non-Hispanic white mothers to begin prenatal care early and are three times as likely to obtain late or no care. Moreover, as Table 1.3 shows, Hispanic mothers as at group are more likely than non-Hispanic black mothers to begin care late or not at all.^* Interestingly, mothers of Cuban background are an anomaly among Hispanic women in their use of prenatal services. They were even more likely than non-Hispanic white mothers to begin prenatal care early in pregnancy, and only 3.7 percent of Cuban mothers in 1985 had late or no care. Such subgroup diversity suggests that the problem of inadequate care among Hispanic women is not due to Hispanic origin per se, but rather to other factors—probably income, education, previous experiences with other health care systems, or a combination of the three.

TABLE 1.3

Percentage of Babies Born to Women Obtaining Early and Late or No Care, by Hispanic and Non-Hispanic Origin, Various Reporting Areas, 1978, 1982, and 1985.

TABLE 1.4

Percentage of Babies Born to Women Obtaining Early and Late or No Care, for Asian or Pacific Islander, American Indian, White, and Black Subgroups and for All Races, United States, 1985.

Other major U.S. subgroups whose use of prenatal care has been analyzed include American Indian (not including native Alaskans) and Asian or Pacific Islander women (Table 1.4). Out of 3.8 million births in the United States in 1985, there were about 41,000 to American Indians and 112,000 to Asian or Pacific Islander women. In that same year, Chinese, Japanese, and Filipino women exhibited particularly high rates of participation in care and were less likely than white women to obtain late or no care; Hawaiian women and other subgroups of women in this category (including Indian, Cambodian, Laotian, Vietnamese, Korean, and other Asian or Pacific Islander women) placed between white and black women in the late or no care category. American Indian women, however, were more likely than either white or black women to obtain late or no care.

Use of prenatal care also varies with a pregnant woman's place of birth. For example, two studies of prenatal care use among selected groups in New York City found that recent immigrants were less likely to obtain late or no care than women born in the United States.^{11, 12} By contrast, a large follow-back survey of 1986 births in Massachusetts found that foreign-born women were more likely to obtain late or no care than U.S.-born women (24 percent versus 37 percent, respectively).¹³ Differences in local health care systems, in the magnitude of language barriers, and in the immigrant populations themselves may account for such variation. Most experts in maternity services believe that recently arrived immigrants are at high risk of obtaining insufficient prenatal care.

Education

Timing of the first prenatal visit correlates highly with level of education. In 1985, 88 percent of mothers with at least some college education began care early in pregnancy, compared with 58 percent of mothers who had less than a high school education.¹⁷ Similarly, the probability that a pregnant woman will obtain care late or not at all decreases steadily as her educational level increases (Table 1.5).

TABLE 1.5

Percentage of Babies Born to Women Obtaining Late or No Care, by Race and Education, United States, 1975, 1980, and 1985.

Given the strong association between higher levels of education and early enrollment in prenatal care, it is useful to consider the proportion of mothers in various subpopulations who have completed high school. In both 1984 and 1985, 79 percent of all mothers had completed at least 12 years of schooling—82 percent of white mothers, 68 percent of black mothers.¹⁸ In 1984, more than twice the proportion of Native American mothers (American Indians and Native Alaskans) as white mothers had less than 12 years of education (38 percent versus 18 percent). Native American mothers were also more likely than black mothers not to have completed high school.¹⁹ For mothers of Hispanic origin, 21 states (not including California and Texas) reported in 1984 on educational attainment; overall, 45 percent of Hispanic mothers giving birth in that year had not completed at least 12 years of school, with subgroup proportions ranging from 59 percent for Mexican mothers to 22 percent for Cuban mothers.²⁰

Birth Order

Obtaining late or no prenatal care is also associated with birth order. In general, the more children a woman has had, the more likely she is to delay care or to seek none at all. In 1985, close to 5 percent of both first and second children were born to mothers who obtained late or no care (Table 1.6). About 6 percent of third births fell into this category, however, and the numbers increased to 9 and 14 percent for fourth and fifth children, respectively. The association of delayed care with greater numbers of children is reflected in the prenatal care use of older mothers: in 1985, nearly 60 percent of births to mothers over age 45 were fifth or subsequent children.²¹

TABLE 1.6

Percentage of Babies Born to Women Obtaining Late or No Care, by Birth Order and Race, Reporting Areas, 1975, 1980, and 1985.

The relationship of prenatal care to birth order varies slightly with race. For white mothers, the percentage of infants born with late or no care is lowest for second births; that number increases steadily with subsequent births. For black mothers, first births are the least likely to have had late or no prenatal care; the risk increases with each subsequent birth. Taffel has concluded that the different age distribution of white and black women at the time of first birth explains these minor variations.²²

Marital Status

Pregnant women who are married are more likely to obtain sufficient prenatal care than pregnant women who are not married (Table 1.7). This relationship holds true among women within the same racial or ethnic group and with similar levels of education.²³ Unmarried mothers are more than three times as likely as married mothers to obtain late or no prenatal care. Unmarried white mothers are almost four times as likely as married white mothers to obtain late or no care; and unmarried black mothers are twice as likely as married black mothers to obtain late or no care. Among unmarried mothers, women of Hispanic origin are most likely to obtain late or no care, followed by white non-Hispanic and then black non-Hispanic mothers.

TABLE 1.7

Percentage of Babies Born to Women Obtaining Late or No Care, by Race and Marital Status, United States, 1975, 1980, and 1985.

The correlation of unmarried status with insufficient prenatal care has become more important in recent years as childbearing among unmarried women has increased, reaching an all-time high of 828,000 births (about 22 percent of all births) in 1985.²⁴ In that year, 12 percent of non-Hispanic white births were to unmarried women, compared with 61 percent of non-Hispanic black births and 23 percent of Hispanic births. The range among the latter group, however, is striking: 51 percent of Puerto Rican births were to unmarried women versus 26 percent of Mexican births.²⁵

The differential between married and unmarried women's timing of entry into prenatal care lessens somewhat with increasing age; however, at any age unmarried women are much more likely than married women to obtain late or no care.²⁶ With regard to the relationship among marital status, age, and use of prenatal care, Ventura and Hendershot analyzed 1980 National Natality Survey data and found that ''teenage mothers began prenatal care earlier if they were married at conception than if they were not . . . and those who were married after conception but before delivery began prenatal care earlier than those who were not married at the time of delivery. The differences [were] substantial."²⁷

Relationships Among Demographic Risk Factors

To assess the comparative importance of selected demographic factors in predicting use of prenatal care, Singh et al. constructed estimates of relative risk for late or no prenatal care for various groups.³⁴ In this analysis, 17 populations (including the total U.S. population) are compared with the group in the United States that has the best rates of prenatal care utilization—married, white, nonpoor women. The question is posed: Compared with the reference group, how many times more likely is group X to obtain late or no prenatal care? As shown in Table 1.8, unmarried women had the greatest relative risk of late or no care. Teenagers, women with less than a high school education, Hispanic women, and women with incomes less than 150 percent of the federal poverty level also faced substantially greater risks.

TABLE 1.8

Number of Mothers Obtaining Late or No Prenatal Care and Relative Risk, Reference Group, Selected Subgroups, and Total Population, United States, 1980.

Some investigators have cross-tabulated use of prenatal care with combinations of three or more demographic measures. Such analyses help in understanding the interaction among risk factors and in pinpointing populations at high risk of insufficient prenatal care. Ingram et al., for example, showed that in 1983 only about 45 percent of unmarried teenagers with less than a high school education obtained early prenatal care (44.1 percent of black teenagers and 46.3 percent of white teenagers). Conversely, about 85 percent of married women age 20 and older with more than a high school education obtained early care (81.9 percent of black women and 90.7 of white women). Generally, this pattern also held true for late or no care.³⁵

Table 1.9 reveals that the impact of poverty on use of prenatal care varies with marital status and that the magnitude of these relationships, in turn, varies with age, race, education, and place of residence. This table underscores the high risk of inadequate prenatal care among poor women who are unmarried, particularly those who are young, not well educated, living in rural areas, or Hispanic.

TABLE 1.9

Percentage of Mothers in Selected Subgroups Obtaining Inadequate Prenatal Care, by Income and Marital Status.

Chapter 3 summarizes several multivariate analyses that consider the relative importance of numerous factors that increase the risk of insufficient prenatal care. The demographic measures discussed in this chapter appear in many of those analyses.

Geographic Pockets of Need

Insufficient prenatal care is concentrated in certain geographic areas, just as it is in certain demographic groups. Analyses of 1985 vital statistics data conducted by the Children's Defense Fund found wide disparities among states in the percentage of infants born to women obtaining late or no care (Table 1.10 and Figure 1.1). For example, a woman giving birth in New York in 1985 was roughly three times as likely as a woman in Michigan or Connecticut to obtain late or no care, and a nonwhite woman in New Mexico or New York was three times as likely as a nonwhite woman in Massachusetts to obtain late or no prenatal care. The analyses also show that states with low percentages of mothers obtaining early care also tend to have high percentages of mothers obtaining late or no prenatal care. In 1985, the three jurisdictions with the lowest percentages of women obtaining early prenatal care and the highest percentages of women with late or no care were New Mexico, the District of Columbia, and Texas.³⁶

TABLE 1.10

Percentage of Babies Born to Women Obtaining Late or No Care, All Races, All States and the District of Columbia, 1969, 1975, 1979, and 1985.

Figure 1.1

Percentage of births to women obtaining late or no prenatal care, United States, all races, 1985. SOURCE: Children's Defense Fund.

Even greater variations in levels of prenatal care can exist within states. For example, although New York State as a whole reports that 9 percent of pregnant women in 1985 had late or no prenatal care (Table 1.10), the percentage was about 18 percent in New York City and far higher in some neighborhoods: in the Mott Haven district of the Bronx, more than 50 percent of births in 1985 were to women with no care or care that began in the third trimester.³⁷

Public health authorities and health planners have long recognized that certain communities show particularly poor rates of prenatal care use, and many of the recent state and local initiatives to combat infant mortality (see Appendix A) have included careful ''mapping" of areas where inadequate use is prevalent. The maps in Figures 1.2 to 1.5 show rates of insufficient prenatal care for various geographic areas. Figures 1.2 and 1.3 are of Wisconsin and North Carolina and display, respectively, patterns of late or no care and patterns of inadequate care in 1985. These maps reveal that rural as well as urban areas exhibit pockets of insufficient prenatal care. Figures 1.4 and 1.5 present a 1985 geographic profile of late or no registration in prenatal care for the District of Columbia and New Haven, Connecticut. Although each of these maps takes a somewhat idiosyncratic approach to defining and displaying geographic variations in use of prenatal care, they effectively communicate the simple fact that pockets of need exist and can be pinpointed. Such maps also show that aggregate data, both state and national, can obscure the fact that use of prenatal care can be exceedingly poor in some smaller areas.

Figure 1.2

Percentage of births to women obtaining late or no prenatal care, Wisconsin, by county, all races, 1985. SOURCE: Wisconsin Department of Health and Social Services.

Figure 1.5

Percentage of births to women obtaining late or no prenatal care, New Haven, Connecticut, by neighborhood, all races, 1982–1985. SOURCE: de Andres P., Backus L., Greene M, Pope E, Scholle R, Singleton C, and Triffin E. Targeting the Problems behind (more...)

Figure 1.3

Percentage of births to women obtaining inadequate care, North Carolina, by county, all races, 1985. Inadequate care is care beginning in the third trimester or four or fewer visits for a pregnancy of 34 or more weeks (Kessner). SOURCE: North Carolina (more...)

Figure 1.4

Percentage of births to women obtaining late or no prenatal care, District of Columbia, by ward, 1985. SOURCE: D.C. Department of Human Services.

These geographic "hot spots" are perhaps best explained by variations in income levels within states and communities. As noted earlier, low income is among the most important factors explaining insufficient use of prenatal care. Thus, census tracts with high concentrations of low-income individuals are likely to have high rates of insufficient prenatal care. Other factors that probably account for these geographic concentrations of need include local inadequacies in the health care system and transportation problems. These obstacles to care and others are taken up in Chapter 2.

Trends in the Use of Prenatal Care

Several special studies^{38, 39, 40, 41, 42} combined with U.S. natality statistics published by the National Center for Health Statistics,⁴³ make possible an analysis of trends in the use of prenatal care from 1969 to 1985. Table 1.11 shows steady improvement from 1969 through 1980 in the percentage of births to mothers receiving prenatal care in the first trimester of pregnancy. Since 1980, however, this percentage has remained stable or decreased. Among black women, declines in early use of prenatal care were registered in 1981, 1982, and 1985.

TABLE 1.11

Percentage of Babies Born to Women Obtaining Early Care, by Race, United States, 1969–1985.

Table 1.12, which displays rates of late or no care, reveals a particularly troubling trend. There has apparently been an increase since 1980 in the percentage of births to women with late or no prenatal care. Although this trend applies to all races, the increase is more pronounced among black women. In 1981, 8.8 percent of births to black women were in this category; by 1985, 10 percent were. In fact, 1985 rates of late or no prenatal care for black women are about the same as those recorded in 1976; improvements in the interim have, in effect, been erased. An analysis of trends in the use of prenatal care between 1970 and 1983 found that early enrollment for black mothers in 1982 was 3.6 percentage points below what it would have been if the 1976 to 1980 trend had continued, and 10.8 percentage points below the expected level based on the 1970 to 1975 trend.⁴⁴

TABLE 1.12

Percentage of Babies Born to Women Obtaining Late or No Care, by Race, United States, 1969–1985.

Given the size and diversity of this country, it is important to consider whether all states mirror these national trends or whether a few states are responsible for observed changes. Table 1.10 shows use of prenatal care for selected years from 1969 to 1985, based on national data for all 50 states and the District of Columbia. (Although 1969 data are not available from 13 states and in 1975 8 states had not yet begun to collect data on time of entry into prenatal care, general state trends can nonetheless be seen.)

There was a clear pattern of improved use of prenatal care on the state level in the early 1970s. All 37 reporting states and the District of Columbia showed smaller percentages of women obtaining late or no care in 1975, as compared to 1969. Most states demonstrated decreases of between 25 and 30 percent, and late or no care decreased by nearly 40 percent in several states between 1969 and 1975.

These favorable trends continued into the late 1970s. From 1975 to 1979, all but 7 of the 43 reporting jurisdictions showed continued declines in the percentage of babies born to women who had received late or no care. However, the rate of decline had slowed, and 6 of the 7 states showed an increase.

Between 1979 and 1985, the increase in the percentage of women obtaining late or no care evidenced in national statistics was mirrored in states from every region of the country. For example, although the number of women beginning care late or not at all in the District of Columbia dropped by 65 percent between 1969 and 1979, the number increased 43 percent between 1979 and 1985. In Oregon and Indiana, the percentages of women who had no prenatal care or none before the seventh month of pregnancy were greater in 1985 than in any other year since 1975. Maine, Massachusetts, and Utah are states with generally low percentages of late or no prenatal care, yet they, too, experienced increases between 1979 and 1985. South Carolina and Florida experienced upward trends of about 30 percent each between 1979 and 1985. Overall, 20 states experienced an increase in the percentage of women who obtained late or no care during this period, and a dozen more states showed no decrease. The Ingram et al. study of the use of prenatal care between 1970 and 1983 confirms the finding that the trends observed on the national level reflect changes in many states from all regions.⁴⁵

It is not known what factors account for these disturbing trends, although a number of social, economic, and other changes in the 1980s have been offered as explanations. These include the increase in unemployment in the early 1980s and the resulting loss of employer-based health insurance and personal income; the increasing proportion of women of childbearing age living in poverty; and the increasing number of employed individuals who have inadequate or no health insurance, along with the continuing erosion of maternity benefits under private plans. Other reasons include the cutbacks in Medicaid eligibility in the early 1980s and the declining proportion of the poor covered by Medicaid; the increasing proportion of births to unmarried women and the growth in the number of households headed by single women; and the increasingly limited capacity of the health care systems relied on by low-income women for prenatal care, caused by funding restrictions and the malpractice squeeze, which is shrinking the pool of obstetric care providers. Many of these issues are discussed in Chapter 2.

Other important trends between about 1970 and the mid-1980s include the following:

a.

The gap between black and white rates of prenatal care use narrowed between 1970 and 1983, although the pace at which it was closing slowed toward the latter half of that interval.⁴⁶

b.

Adolescent mothers were more likely to obtain early care in 1985 than they were in 1970. Generally, there has been a decline in late or no care among teenagers; however, the decline has been least for the youngest mothers, and, as among older women, progress has slowed in the 1980's.⁴⁷

c.

As for black women, increasing percentages of some subgroups of Hispanic women-particularly Mexican women—obtained late or no care in the 1980s (Table 1.3).

d.

In recent years, there has been virtually no improvement in the proportion of women with little education who obtained late or no care (Table 1.5).

e.

Between 1970 and 1985, unmarried mothers, particularly unmarried white mothers, exhibited some of the most rapid decreases in late registration for prenatal care (Table 1.7).

f.

Data from 1975, 1980, and 1985 consistently show that for black women, first births are the least likely to have had late or no prenatal care; for white women, second births are the least likely to fall in this category (Table 1.6).

Summary

Several interrelated demographic factors put women at risk for insufficient prenatal care: being in a racial or ethnic minority group (especially American Indian, black, and Hispanic), being under 20 (particularly, under 15), having less than a high school education, higher parity, and being unmarried. Geographic analysis also reveals that insufficient use of prenatal care is often concentrated in areas that can be easily identified. All of these risk factors, in turn, are closely related to poverty, which is one of the most important factors consistently associated with insufficient prenatal care.

Unfortunately, the steady progress of the 1970s in drawing more women into prenatal care early in pregnancy ended in the 1980s. On the important measure of late or no care, there has actually been a reversal of progress, particularly for black women.

References and Notes

1.

American College of Obstetricians and Gynecologists. Standards for Obstetric-Gynecologic Services, 6th ed. Washington, D.C., 1985.

2.

American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Washington, D.C., 1983.

3.

Morehead MA, Donaldson RS, and Seravalli MS. Comparisons between OEO Neighborhood Health Centers and other health care providers of ratings of the quality of health care. Am. J. Public Health 61:1294–1306, 1971. [PMC free article: PMC1529743] [PubMed: 5563250]

4.

Hughey MJ. Routine prenatal and gynecologic care in prepaid group practice. J. Am. Med. Assoc. 256:1775–1777, 1986. [PubMed: 3747088]

5.

Kessner DM, Singer J, Kalk CE, and Schlesinger ER. Infant death: An analysis by maternal risk and health care. In Contrasts in Health Status, Vol. 1. Washington, D.C.: National Academy of Sciences, 1973.

6.

National Center for Health Statistics. Comparability of reporting between the birth certificate and the National Natality Survey. Prepared by Querec LJ. Vital and Health Statistics, Series 2, No. 83. DHEW Pub. No. (PHS)80-1357. Washington, D.C.: Government Printing Office, 1980.

7.

National Center for Health Statistics. Birth certificate completion procedures and the accuracy of Missouri birth certificate data. Prepared by Land G and Vaughan B. Priorities in Health Statistics: Proceedings of the 19th National Meeting of the Public Health Conference on Records and Statistics, August 1983. DHHS Pub. No. (PHS)81-1214, Washington, D.C.: Government Printing Office, 1983, pp.263–265.

8.

Kotelchuck M. The mismeasurement of prenatal care adequacy in the U.S. and a proposed alternative two-part index. Paper presented at the American Public Health Association annual meeting, New Orleans, 1987.

9.

Hughes D, Johnson K, Rosenbaum S, Simons J, and Butler E. The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1988. The definition of adequate care used in these analyses differs slightly from that in the Kessner index: gestational age at which measurement begins is 17 weeks in this modified index versus 13 or fewer weeks in the Kessner index.

10.

National Center for Health Statistics. Births of Hispanic parentage, 1985. Prepared by Ventura SJ, Monthly Vital Statistics Report, Vol. 36, No. 11 Suppl. DHHS Pub. No. (PHS)88-1120. Hyattsville, Md., 1988.

11.

Chao S, Imaizumi S, Gorman S, and Lowenstein R. Reasons for absence of prenatal care and its consequences. New York: Department of Obstetrics and Gynecology, Harlem Hospital Center, 1984.

12.

Kalmuss D, Darabi KF, Lopez I, Caro FG, Marshall E, and Carter A. Barriers to Prenatal Care: An Examination of Use of Prenatal Care Among Low-Income Women in New York City. New York: Community Service Society, 1987.

13.

Johnson S, Gibbs E, Kogan M, Kapp C, and Hansen JH. Massachusetts Prenatal Care Survey—Factors Related to Prenatal Care Utilization. Boston: SPRANS Prenatal Care Project, Massachusetts Department of Public Health, 1987.

14.

Hughes D et al. Op. cit., p. 29.

15.

The Financing of Maternity Care in the United States. New York: Alan Guttmacher Institute, 1987, p. 45.

16.

National Center for Health Statistics, Division of Vital Statistics. Unpublished data, 1984.

17.

National Center for Health Statistics. Advance report of final natality statistics, 1985. Monthly Vital Statistics Report, Vol. 36, No. 4 Suppl. DHHS Pub. No. (PHS)87-1120. Hyattsville, Md., 1987, p. 9.

18.

Ibid., p. 8.

19.

National Center for Health Statistics. Characteristics of American Indian and Alaska native births, United States, 1984. Prepared by Taffel SM. Monthly Vital Statistics Report, Vol. 36, No. 3 Suppl. DHHS Pub. No. (PHS)87-1120. Hyattsville, Md., 1987.

20.

National Center for Health Statistics. Births of Hispanic parentage, 1985. Op. cit.

21.

National Center for Health Statistics. Advance report of final natality statistics, 1985. Op. cit., table 2, p. 14.

22.

National Center for Health Statistics. Prenatal care, United States, 1969–75. Prepared by Taffel SM. Vital and Health Statistics, Series 21, No. 33. DHEW Pub. No. (PHS)78-1911. Washington, D.C.: Government Printing Office, 1978.

23.

Singh S, Torres A, and Forrest JD. The need for prenatal care in the United States: Evidence from the 1980 National Natality Survey. Fam. Plan. Perspect. 17:118–124, 1985. [PubMed: 3842661]

24.

National Center for Health Statistics. Advance report of final natality statistics, 1985. Op. cit., p. 7.

25.

National Center for Health Statistics. Births of Hispanic parentage, 1985. Op. cit., p. 9.

26.

Singh S et al. Op. cit., p. 121.

27.

Ventura SJ and Hendershot GE. Infant health consequences of childbearing by teenagers and older mothers. Public Health Rep. 99:138–146, 1984, p. 144. [PMC free article: PMC1424553] [PubMed: 6424162]

28.

Placek P. The 1980 National Natality Survey and National Fetal Mortality Survey: Methods used and PHS agency participation. Public Health Rep. 99:111–116, 1984. [PMC free article: PMC1424549] [PubMed: 6424159]

29.

National Center for Health Statistics. National Survey of Family Growth, Cycle III sample design weighting, and variance estimation. Prepared by Bachrach C, Horn MC, Mosher WD, and Shitmizu I. Vital and Health Statistics, Series 2, No. 98. Washington, D.C.: Government Printing Office, 1985. [PubMed: 3832630]

30.

Singh S et al. Op. cit.

31.

Unpublished data from the 1982 National Survey of Family Growth, provided by the Family Growth Statistics Branch, Division of Vital Statistics, National Center for Health Statistics, U.S. Public Health Service.

32.

Johnson S et al. Op. cit., p. 19.

33.

Singh S et al. Op. cit., p. 120.

34.

Ibid., p. 123.

35.

Ingram DD, Makuc D, and Kleinman JC. National and state trends in use of prenatal care, 1970–83. Am. J. Public Health 76:415–423, 1986, p. 417. [PMC free article: PMC1646502] [PubMed: 3953919]

36.

Hughes D et al. Op. cit., p. 70.

37.

Kalmuss D et al. Op. cit., p. ii.

38.

Ingram DD et al. Op. cit.

39.

Johnson K, Rosenbaum S, and Simons J. The Data Book. Washington, D.C.: Children's Defense Fund, 1985.

40.

Hughes D, Johnson K, Rosenbaum S, and Simons J. Maternal and Child Health Data Book: The Health of America's Children. Washington, D.C.: Children's Defense Fund, 1986.

41.

Hughes D, Johnson K, Rosenbaum S, Simons J, and Butler E. The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1987.

42.

Hughes D et al. The Health of America's Children: Maternal and Child Health Data Book. 1988. Op. cit.

43.

National Center for Health Statistics. Prenatal care, United States, 1969–75. Op. cit.

44.

Ingram DD et al. Op. cit., p. 420.

45.

Ibid., p.421–422.

46.

Ibid., p. 415.

47.

Johnson K. The demographics of prenatal care utilization. Paper prepared for the Committee on Outreach for Prenatal Care. Institute of Medicine, Washington, D.C., 1988.

Footnotes

*

The 1989 revision of the U.S. Standard Certificate of Live Birth, overseen by the National Center for Health Statistics, recommends several changes that, if adopted by all states, should improve analyses of the use and effectiveness of prenatal care and of interstate differences.

*

All data in this section are vital statistics compiled by the National Center for Health Statistics, unless otherwise noted.

*

Although Table 1.3 and some others that follow present data for several years in addition to 1985, discussion of trends does not begin until later in this chapter. Here, the focus is on 1985 patterns of use only.