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The borderline between health and disease is less distinctly marked during gestation, and therefore, it accordingly becomes necessary to keep pregnant patients under strict supervision, and to be constantly on the alert for the appearance of untoward symptoms.

—J. Whitridge Williams (1903)

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INTRODUCTION

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As emphasized above by Williams, prenatal care is important. According to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) a comprehensive antepartum program is defined as: “a coordinated approach to medical care, continuous risk assessment, and psychological support that optimally begins before conception and extends throughout the postpartum period and interconceptional period.”

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PRENATAL CARE IN THE UNITED STATES

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Almost a century after its introduction, prenatal care has become one of the most frequently used health services in the United States. In 2001, there were approximately 50 million prenatal visits. The median was 12.3 visits per pregnancy, and many women had 17 or more visits. Still, as seen from Figure 9-1, 6 to 7 percent of women in this country have late or no prenatal care. In 2014, the percentages of non-Hispanic white, Hispanic, and African-American women who received inadequate or no prenatal care were 4.3, 7.5, and 9.7, respectively (Child Trends, 2015).

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FIGURE 9-1

Percentage of births to mothers who received late or no prenatal care—United States, 1990–2014. (Data from Child Trends, 2015.)

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The Centers for Disease Control and Prevention (CDC) (2000) analyzed birth certificate data and found that half of women with delayed or no prenatal care wanted to begin care earlier. Barriers to care varied by social and ethnic group, age, and payment method. The most common reason cited was late recognition of pregnancy by the patient. The second most commonly cited obstacle was lack of money or insurance. The third was inability to obtain an appointment.

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Prenatal Care Effectiveness

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Care designed during the early 1900s focused on lowering the extremely high maternal mortality rate. Prenatal care undoubtedly contributed to the dramatic decline in this mortality rate from 690 deaths per 100,000 births in 1920 to 50 per 100,000 by 1955 (Loudon, 1992). And, the low current maternal mortality rate of 10 to 15 per 100,000 is likely associated with the high utilization of this care (Xu, 2010). Indeed, data from 1998 to 2005 from the Pregnancy Mortality Surveillance System identified a fivefold increased risk for maternal death in women who received no prenatal care (Berg, 2010).

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Other reports also attest to prenatal care efficacy. In a study of almost 29 million births, the risk for preterm birth, stillbirth, early and late neonatal death, and infant death rose linearly with decreasing prenatal care (Partridge, 2012). Similarly, Leveno and associates (2009) found that a ...

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