Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care

In 2010, Preventing Low Birthweight celebrated it 25th anniversary. The report, one of the most influential policy statements ever issued regarding obstetric health care delivery, linked prenatal care to a reduction in low birthweight (LBW). Medicaid coverage for prenatal care services was subsequently expanded and resulted in increased prenatal care utilization. However, the rate of LBW failed to decrease. This well-intentioned expansion of prenatal care services did not change the structure of prenatal care. A single, standardized prenatal care model, largely ineffective in the prevention of LBW, was expanded to a heterogeneous group of patients with a variety of medical and psychosocial risk factors. Reinventing prenatal care as a flexible model, with content, frequency, and timing tailored to maternal and fetal risk, may improve adverse birth outcomes. Risk-appropriate prenatal care may improve the effectiveness of prenatal care for high-risk patients and the efficiency of prenatal care delivery for low-risk patients.     

Postdates pregnancy in an indigent population: the financial burden

OBJECTIVE: The objective of this study was to determine the comparative financial burden of twice-weekly fetal testing from 41 weeks of gestation until delivery, as compared with early dating ultrasound evaluation in an indigent population. STUDY DESIGN: All women who were seen for antepartum testing for postdating pregnancy at Lyndon Baines Johnson Hospital were enrolled. Patient age, parity, gestational age at initiation of prenatal care, the number of prenatal visits, gestational age at first ultrasound scan, and the number of biophysical profiles that were performed before delivery were recorded. The labor and delivery database was searched for all deliveries at >41 weeks of gestation. The charge for a single ultrasound scan at <20 weeks of gestation was compared with twice-weekly testing in the population as a whole with the use of three strategies (no dating ultrasound scans and biophysical profiles until delivery, routine dating ultrasound scan and routine induction at 41 weeks of gestation, and current practice at our institution). RESULTS: One hundred twenty-seven subjects with postdated pregnancy were enrolled (mean age, 25.2 years; median parity, 0 [range, 0-6]). The mean gestational age at the initiation of prenatal care was 21.2 +/- 10.5 weeks. Forty-seven women (38.0%) initiated care at <20 weeks. The mean number of biophysical profiles performed before delivery was 1.5 +/- 1.34; the mean gestational age at delivery was 42.1 +/- 0.87 weeks (spontaneous labor, 39.6%; induced labor, 40.4%). The charge for a biophysical profile is $492.90 US dollars and $551.00 US dollars for a 20-week ultrasound scan; there is no difference in the charge for induced or spontaneous labor. During the 4-month study period, 1638 patients were delivered at our hospital; 341 patients were delivered at >41 weeks of gestation. The estimated financial burden of antenatal testing of 341 patients from 41 weeks to delivery was calculated to be $252,118 US dollars, compared with $902,538 US dollars for a single ultrasound scan at 20 weeks for the entire population of 1638 patients. The estimated financial burden of current practice (10% of patients with no prenatal care, 38% of patients with examination at <20 weeks who were eligible for dating ultrasound scanning, and 37% of patients with examination for postdate testing) was $402,457 US dollars. CONCLUSION: Patients who were seen for postdate antepartum testing in an indigent population lack early initiation of prenatal care and early ultrasound scans. Because on average only 1.5 biophysical profiles are performed per patient before delivery, routine early ultrasound scanning and routine induction at 41 weeks of gestation would add considerable financial burden to the system.     

CENTERING PREGNANCY: An Interdisciplinary Model of Empowerment

This is a time of change within the health care system. This has created a challenge for health care providers to develop creative new patterns that will provide quality service within a system that is mandating more economy and efficiency. The Centering Pregnancy program abolishes routine prenatal care by bringing women out of examination rooms and into groups for their care. The design incorporates the three components of prenatal care—risk assessment, education, and support—into one entity. Women are placed into groups of 8 to 12 based on estimated dates of delivery and meet for ten 90-minute prenatal or postpartum visits at regular intervals. At these visits, standard prenatal risk assessment is completed within the group setting, an educational format is followed that uses a didactic discussion format, and time is provided for women to talk and share with one another. By incorporating these three components into one whole, emphasis is placed on their collective importance. Women are encouraged to take responsibility for themselves; this leads to a shift in the client-provider power base. Evaluative data demonstrated that 96% of the women preferred receiving their prenatal care in groups. This model is interdisciplinary in design and demonstrates provider satisfaction, as well as efficiency in delivery of care. It is an excellent model for the care of teens and for midwives and nurse practitioners to lead. The combination of satisfaction, good outcomes, and effective delivery of care makes this an attractive model for agencies to implement.     

A study to determine the incidence and prevalence of newly discovered human immunodeficiency virus infection during the prenatal care period

OBJECTIVES: This study asked the following questions: 1) Does HIV testing in pregnancy identify women who previously were not known to be HIV positive? 2) When in pregnancy are women identified as HIV infected? 3) Does HIV seroconversion occur during the prenatal care period? METHODS: Medical records of 97 women from two primarily indigent care hospitals in Houston, TX who were found to be HIV positive at delivery were reviewed to determine if they had tested positive during the prenatal care period. Demographics and time of gestation of the prenatal testing also were recorded. The outcome measures were: 1) number of women found positive during prenatal care; 2) week of gestation at discovery of HIV positivity; and 3) number of women seroconverting between the initiation of prenatal care and delivery. RESULTS: Thirty women were known to be HIV positive prior to pregnancy. Fifty-six women were found to be positive during prenatal care and the seropositivity of 44 was discovered before the 34th week of pregnancy. Ten women were found to be positive at their first prenatal visit, which occurred after the 34th week. Date of testing was unknown for two women. Eleven women who received no prenatal care were found to be HIV positive at delivery. There were no seroconversions while women were under prenatal care. CONCLUSIONS: HIV testing at delivery did not find any HIV-positive women who had tested negative during prenatal care. Testing is very important for women who do not receive prenatal care. Making certain that high-risk women get into prenatal care also is very important.     

Four countries,four ways of discussing low-risk pregnancy and normal delivery: in France,Germany, The Netherlands,and the United Kingdom

The 2012 “4 countries meeting” of the French, Dutch, British and German Societies of Gynaecology and Obstetrics (CNGOF, NVOG, RCOG, DGGG) was dedicated to the topic “Low-risk pregnancy and normal delivery”. The objective was to compare how each country organises prenatal care and normal delivery. The discussion is outlined in the article and provides new opportunities to learn from each other’s strengths in order to provide the highest level of care regardless of social, demographic, educational and clinical differences.     

A Review of Prenatal Home‐Visiting Effectiveness for Improving Birth Outcomes

ObjectiveTo determine the effectiveness of prenatal home visiting for improving prenatal care utilization and preventing preterm birth and low birth weight.Data SourcesMedline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Social Work Abstract databases were searched for articles that examined prenatal home‐visiting and prenatal care utilization or neonatal outcomes, with additional ascendancy and descendancy searches. Listservs were also used to identify unpublished evaluations.Study SelectionQuantitative studies meeting the following criteria were included in the analyses: published between 1985 and 2009, published in English, reported providing prenatal home visiting, and reported on prenatal care utilization or a neonatal outcome.Data ExtractionStudy characteristics and findings related to prenatal care utilization, gestational age, and birth weight were abstracted independently by at least two authors. Study quality was assessed across five domains.Data SynthesisThe search yielded 28 studies comparing outcomes for women who did and did not receive prenatal home visiting, with 14 (59%) using an RCT design. Five (17%) studies reporting on prenatal care utilization found a statistically significant improvement in use of prenatal care for women with home visiting. Of 24 studies reporting an effect on birth outcomes, five (21%) found a significant positive effect on gestational age, and seven of 17 (41%) found a significant positive effect on birth weight.ConclusionsMore evidence suggests that prenatal home visiting may improve the use of prenatal care, whereas less evidence exists that it improves neonatal birth weight or gestational age. These findings have implications for implementing Title II of the Affordable Care Act.     

Relationship between prenatal care and maternal complications in women with preeclampsia: Implications for continuity and discontinuity of prenatal care

ObjectivePrenatal care is associated with better pregnancy outcome and may be a patient safety issue. However, no studies have investigated the types and quality of prenatal care provided in northern Taiwan. This retrospective study assessed whether the hospital-based continuous prenatal care model at tertiary hospitals reduced the risk of perinatal morbidity and maternal complications in pre-eclampsia patients.Materials and MethodsOf 385 pre-eclampsia patients recruited from among 23,665 deliveries, 198 were classified as patients with little or no prenatal care who received traditional, individualized, and physician-based discontinuous prenatal care (community-based model), and 187 were classified as control patients who received tertiary hospital-based continuous prenatal care.ResultsThe effects on perinatal outcome were significantly different between the two groups. The cases in the hospital-based care group were less likely to be associated with preterm delivery, low birth weight, very low birth weight, and intrauterine growth restriction. After adjustment of confounding factors, the factors associated with pregnant women who received little or no prenatal care by individualized physician groups were diastolic blood pressure ≥105 mmHg, serum aspartate transaminase level ≥150 IU/L, and low-birth-weight deliveries. This study also demonstrated the dose–response effect of inadequate, intermediate, adequate, and intensive prenatal care status on fetal birth weight and gestational periods (weeks to delivery).ConclusionThe types of prenatal care may be associated with different pregnancy outcomes and neonatal morbidity. Factors associated with inadequate prenatal care may be predictors of pregnancy outcome in pregnant women with pre-eclampsia.     

The Role of the Nurse in Labor and Delivery as Perceived by Nurses and Patients

A study was conducted to examine the role of the labor and delivery room nurse as perceived by expectant mothers trained in the Lamaze method of preparation for childbirth (L/RC), expectant mothers not trained in the Lamaze method (RC), and labor and delivery room nurses. All expectant mothers received baseline prenatal education by attending Red Cross Preparation for Parenthood. Perceptions were measured through a Q-sort of 50 items constructed for this study. Each item described a nursing behavior in labor and delivery. Differences between Q-sorts of expectant mothers and labor and delivery room nurses were insignificant. The collected data showed that labor and delivery room nurses were meeting the expectations of expectant mothers, both trained and not trained in the Lamaze method. Perceptions of the nurse's role in labor and delivery differed slightly so that individualization of care is important.     

Predicting prematurity: the mammary stimulation test.

The MST appears to have theoretical rationale, predictive utility, simplicity, safety, and low cost that suggests that its routine use in prematurity prevention may ultimately save significant health care dollars. Presently, the MST should be used as an adjunct to prenatal care until further and more definitive investigation has been conducted; however, it seems promising that the MST will provide some reassurance in patients with negative tests and signify patients that are at significant risk for premature delivery (positive MST). It is hoped that further investigation will validate the MST's use in prematurity prevention in order to help decrease the incidence of preterm delivery.     

Screening for substance use in pregnancy: a practical approach for the primary care physician

Our goal was to identify risk factors for substance use during pregnancy for primary care physicians so that we could assess a woman's risk of alcohol or illicit drug use. Participants were 2002 Medicaid-eligible pregnant women with < or =2 visits to prenatal care clinics in South Carolina and Washington State. Structured interviews were used to collect data. Logistic regressions and classification and regression trees identified predictors for pregnant women at high risk for substance use. Approximately 9% of the sample reported current use of either drugs or alcohol or both. Past use of alcohol or cigarettes, including during the month before pregnancy, most differentiated current drug or alcohol users from current nonusers. Our analysis suggests that primary care physicians can ask 3 questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.     

A Tri‐Service Perspective on the Implementation of a Centering Pregnancy Model in the Military

With the rising cost of health care, group prenatal care has come into the forefront as a viable, evidence‐based option for care delivery. In this article, the authors from three different branches of service (Army, Navy, Air Force) review the strategies and challenges of implementing a centering pregnancy model at military treatment facilities.     

Prenatal care: limitations and opportunities

Prenatal care is a venerable tradition in the U.S. health care system and one that deserves critical examination. Inordinate amounts of public and personal resources are expended on a tradition of care that has not proven itself equal to current perinatal prevention challenges. In this article, the evolution of prenatal care is reviewed, its efficacy is critiqued, and efforts at restructuring the content and processes of care are examined. Three promising alternatives to the dominant medical model are described: the comprehensive prenatal care approach illustrated by many publicly funded prenatal clinics, the prenatal empowerment model as exemplified by midwifery care, and the prenatal group model as illustrated by CenteringPregnancy. Nurses are called upon to champion prenatal options for women.     

Preterm delivery and the severity of violence during pregnancy.

OBJECTIVE: To determine the severity and consequences of physical violence during pregnancy among participants in a health department prenatal care coordination program. STUDY DESIGN: The prospective cohort study included all program participants from 1994 to 1996. Care coordinators screened participants for physical violence during pregnancy using a validated, systematic assessment protocol three times during prenatal care. The protocol was linked with prenatal records, delivery records and infant records to document complications and infant outcomes. Multiple logistic regression was used to assess the relationship between severe physical violence during pregnancy and pregnancy outcome while controlling for confounding factors. RESULTS: Among the 550 participants, 13.5% reported violence during pregnancy; it included 6.7% severe violence (hitting, kicking, injury with a weapon and abdominal injury) and 6.7% moderate violence (threats, slapping, shoving and sexual abuse). Severe physical prenatal violence was significantly associated with spontaneous preterm labor, preterm delivery, very preterm delivery, very low birth weight, preterm/low birth weight, mean birth weight, mean newborn hospital charges, five-minute Apgar < 7, neonatal intensive care unit admission, and fetal or neonatal death. Body site injured, timing of violence and number of violent incidents were significant factors associated with violence during pregnancy and preterm delivery. CONCLUSION: Because severe physical violence during pregnancy was a significant problem in this population, intervention programs are needed to reduce prenatal violence and its consequences.     

Potential role of prenatal care in reducing maternal and perinatal mortality in sub-Saharan Africa

Prenatal care has been implemented in developing countries according to the same mode as applied in industrialized countries without considering its real effectiveness in reducing maternal and neonatal mortality. Several recent studies suggest that the goals should be revisited in order to implement a program of prenatal care based on real scientific evidence. Based on the current literature, we propose a potentially effective content for prenatal care adapted to the context of developing countries. Four antenatal consultations would be enough if appropriately timed at 12, 26, 32 and 36 weeks pregnancy. The purpose of these consultations would be: 1) to screen for three major risk factors, which, when recognized, lead to specific action: uterine, scare, malpresentation, premature rupture of the membranes; 2) to prevent and/or detect (and treat) specific complications of pregnancy: hypertension, infection (malaria, venereal disease, HIV, tetanus, urinary tract infection); anemia and trace element deficiencies, gestational diabetes mellitus; 3) to provide counseling, support and information for pregnant women and their families (including the partner) concerning: severe signs and symptoms of pregnancy and delivery, community organization of emergency transfer, delivery planning. These potentially effective actions can only have a real public health impact if implemented within an organized maternal health system with a functional network of delivery units, if truly quality care is given, and if the relationships between health care providers and the population are based on mutual respect. Sub-Saharan African women use prenatal care extensively when it is accessible; this opportunity must be used to implement evidence-based actions with appropriate and realistic goals.     

Why Is the Cesarean Delivery Rate So High in Alabama? An Examination of Risk Factors, 1991–1993

ABSTRACT: Background : Cesarean delivery is now the most frequently performed major operative procedure for childbearing women in the United States. Many of these operations are reported to be unnecessary, and millions of dollars could be saved by reducing their frequency. Methods : Method of delivery was added to the 1989 revision of the standard certificate of live birth. Alabama also added questions on the source of payment for delivery and the provider of prenatal care in 1991, which enabled an investigation of the risk factors for cesarean delivery that occurred in the state during this period. Results : One of every four births in Alabama is by cesarean delivery. The risk of cesarean delivery is not random, and the risk factors include mother's race and age, coverage by private insurance, birthweight, setting where the mother received prenatal care, mother's educational attainment, live birth order, and complications of labor and delivery. Conclusion : With present concerns about health care reform and the costs of health care, a reduction in the cesarean delivery rate could result in significant cost savings.     

Modifying effect of prenatal care on the association between young maternal age and adverse birth outcomes

ObjectivesThe objectives were to investigate the prevalence of adverse birth outcomes according to maternal age range in the city of Rio de Janeiro, Brazil, in 2002, and to evaluate the association between maternal age range and adverse birth outcomes using additive interaction to determine whether adequate prenatal care can attenuate the harmful effect of young age on pregnancy outcomes.MethodsA cross-sectional analysis was performed in women up to 24 years of age who gave birth to live children in 2002 in the city of Rio de Janeiro. To evaluate adverse outcomes, the exposure variable was maternal age range, and the outcome variables were very preterm birth, low birth weight, prematurity, and low 5-minute Apgar score. The presence of interaction was investigated with the composite variable maternal age plus prenatal care. The proportions and respective 95% confidence intervals were calculated for adequate schooling, delivery in a public maternity hospital, and adequate prenatal care, and the outcomes according to maternal age range. The chi-square test was used. The association between age range and birth outcomes was evaluated with logistic models adjusted for schooling and type of hospital for each prenatal stratum and outcome. Attributable proportion was calculated in order to measure additive interaction.ResultsOf the 40,111 live births in the sample, 1.9% corresponded to children of mothers from 10-14 years of age, 38% from 15-19 years, and 59.9% from 20-24 years. An association between maternal age and adverse outcomes was observed only in adolescent mothers with inadequate prenatal care, and significant additive interaction was observed between prenatal care and maternal age for all the outcomes.ConclusionAdolescent mothers and their newborns are exposed to greater risk of adverse outcomes when prenatal care fails to comply with current guidelines.     

The effect of integrating substance abuse treatment with prenatal care on birth outcome.

OBJECTIVE: To determine whether engaging pregnant substance abusers in an integrated program of prenatal care and substance abuse treatment would improve neonatal outcomes. STUDY DESIGN: The subjects were women who voluntarily enrolled in Project Link, an intensive outpatient substance abuse treatment program at Women and Infants Hospital, Providence, RI. A total of 87 women received substance abuse treatment in conjunction with their prenatal care; the comparison group of 87 women received equivalent prenatal care but did not enroll in the substance abuse treatment program until after they delivered. The two groups of women were similar demographically and socioeconomically and had similar substance abuse histories. Univariate and multivariate analyses were performed. The key outcomes were gestational age at delivery, birth weight, preterm delivery, Apgar scores, and neonatal intensive care admission rate. Factors controlled in the multivariate models included demographics, socioeconomic status, parity, and prenatal care. RESULTS: Infants born to women who enrolled prenatally were 400 gm heavier (p < 0.001), and their gestational age was 2 weeks longer (p < 0.001) than infants of mothers enrolled postpartum. In addition, they were approximately one-third as likely to be born with a low birth weight (p < 0.01) and approximately one-half as likely to be admitted to the neonatal intensive care unit (p < 0.05). CONCLUSION: Neonatal outcome is significantly improved for infants born to substance abusers who receive substance abuse treatment concurrent with prenatal care compared with infants born to substance abusers who enter treatment postpartum.     

Factors Associated With Prenatal Care Use Among Peripartum Women in the Mother-Infant Rapid Intervention at Delivery Study

Objective: To evaluate factors associated with receiving prenatal care among women who present in labor without human immunodeficiency virus documentation using the results of a previous study, Mother-Infant Rapid Intervention at Delivery.
Design: Prospective, multicenter study.
Setting: Eighteen hospitals in the United States.
Participants: The present analysis is based on 667 peripartum women who completed a face-to-face interview after delivery. For purposes of this analysis, human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women were considered together as the "study group."
Methods: The original study, Mother-Infant Rapid Intervention at Delivery, offered rapid human immunodeficiency virus testing to women in labor without human immunodeficiency virus testing documentation at 18 hospitals in the United States. This secondary study evaluated factors related to prenatal care, among participants who agreed to an interview after delivery.
Results: Interviews were completed by 667 women. Of these, 26.8% reported no prenatal care before admission to labor and delivery. These women were more likely to have been born in the United States, have other children, used alcohol, and reported being unhappy. Those who reported receiving prenatal care were more likely to have had Medicaid, stronger social support, and reported good health.
Conclusion: Women who are unlikely to receive prenatal care lack social support and are more likely to have additional social stressors. Medicaid may provide an important safety net to enhance access to care, because those with Medicaid were more likely to receive prenatal care. Further research is necessary to identify nontraditional models of care to enhance outreach to women at risk for no prenatal care.     

Childhood Maltreatment History,Posttraumatic Relational Sequelae,and Prenatal Care Utilization

ObjectiveTo test the hypothesis that childhood maltreatment history would be associated with inadequate prenatal care utilization.DesignA post-hoc analysis of a prospective cohort study of the effects of post traumatic stress disorder (PTSD) on pregnancy outcomes.SettingRecruitment took place via prenatal clinics from three academic health systems in southeast Michigan.ParticipantsThis analysis included 467 diverse, nulliparous, English-speaking adult women expecting their first infants.MethodsData were gathered from structured telephone interviews at two time points in pregnancy and from prenatal medical records.ResultsContrary to our hypothesis, history of childhood maltreatment was associated with better likelihood of using adequate prenatal care. Risk for inadequate prenatal care occurred in association with the posttraumatic stress and interpersonal sensitivity that can result from maltreatment, with low alliance with the maternity care provider, and with public insurance coverage. Prior mental health treatment was associated with using adequate prenatal care.ConclusionWhen childhood maltreatment survivors were resilient or had used mental health treatment, they were more likely to utilize adequate prenatal care. The maternity care relationship or service delivery model (e.g., no continuity of care) as well as structural factors may adversely affect utilization among PTSD-affected survivors. Since inadequate care was associated with adverse outcomes, further studies of these modifiable factors are warranted.     

Maternal-Fetal Physical Assessment in the Home Setting: Role of the Advanced Practice Nurse

Maternal-fetal physical assessment in the home setting reflects a review of the literature, AWHONN's practice guidelines, and the authors' clinical experience. The goals of prenatal home care and the role of the advanced practice nurse are described. Emphasis is placed on the maternal-fetal physical assessments that allow the advanced practice nurse to provide additive or substitutive prenatal care visits in the home. Delivering prenatal care in the home by the advanced practice nurse is an alternative type of health-care delivery for pregnant women.