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18 and wanted at the time of conception. It is apparent, for example, that both teenagers and unmarried women experience higher than average rates of Tow birthweight; they also report higher rates of unintended pregnancies. It has been suggested that a woman who has planned for and welcomes her pregnancy will follow the health practices necessary to increase the chances of a successful pregnancy outcome more aclequately than a woman with an undesired pregnancy. Recent data from the 1980 National Natality Survey support this thesis. In the portion of that survey focused on married women only, wantedness of pregnancy had a strong relationship to seeking prenatal care. Women who wanted a child at the time they became pregnant were more likely to receive care early in pregnancy than were those who would have preferred to have had a chilct at a later time. Women who had not planned to have another child showed the most delay in seeking prenatal care. These factors accounted for about a third of the black/white ctifferential in the number of prenatal visits.~4 Unmet Need for Family Planning The large number of unintended pregnancies in the United States, the percentage of women at risk of unintended pregnancy who do not use contraception, and the number of abortions indicate that existing family planning strategies are not fully adequate. The reasons for this problem range from service inadequacies to the knowledge, attitudes, and practices of inclividual couples. The unmet need appears to be largest among two groups at particularly high risk of low birthweight, the poor and the young. It has been estimated that in 1981, about 9.5 million Tow-income and 5 million sexually active teenagers neecled subsidized (i.e., supported at least in part by public funds) family planning care, but over 40 percent of both groups did not obtain medically supervised contraceptive care.15 For this reason, the committee emphasizes the importance of Title X of the Public Health Service Act. Title X authorizes project grants to public and private nonprofit organizations for the provision of family planning services to all who need and want them, inclucling sexually active teenagers, but with priority given to low-income persons. The committee urges that federal funds be made generously available to meet the documented need for family planning. The Title X program and family planning services generally should be regarded as important parts of the public effort to prevent low birth- weight. The prevention of unwanted pregnancies in sexually active adolescents, particularly those under 17 who are unmarried, should receive special atten- tion. Infants born to members of this group have substantially higher rates of low birthweight, neonatal mortality, and postneonatal mortality and mor- bidity than infants born to older mothers. THE IMPACT OF PRENATAL CARE After a comprehensive review of the literature on the value of prenatal care, the committee concluded that the overwhelming weight of the evi- dence is that prenatal care reduces low birthweight. This finding is strong

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19 enough to support a broad, national commitment to ensuring that all pregnant women in the United States, especially those at medical or socioeconomic risk, receive high-quality prenatal care. Prenatal Care Studies In reaching this con- clusion, the committee re- viewed two groups of studies designed to deter- mine the value of prenatal care in the prevention of Tow birthweight. The first group consisted of studies involving large data sets, usually a year of live births in a large geographic area or in the nation as a whole. The second) includecT stucI- ies evaluating the impact on pregnancy outcome of specific programs offering prenatal care and related services. Conclusions drawn from both classes of studies are limitect by a variety of problems inherent in all studies of the effectiveness of prenatal care. These problems, detailed in the full report, involve difficulties in research design, inadequate definitions of the content of prenatal care, selection bias, and other issues. The committee noted that a major theme of virtually all the studies re- viewed is that prenatal care is most effective in reducing the chance of low birthweight among high-risk women, whether the risk derives from medical factors, sociodemographic factors, or both. This finding has important implications for targeting interventions; it also suggests that differences in the risk status of various study populations may partially explain variations in the prenatal care effects observed across studies. All of the studies reviewed that are basect on large numbers of cases, particularly those using vital statistics data, show that prenatal care exerts a positive effect on birthweight. Unfortunately, because content of prenatal care is not defined carefully in many of these studies, it is not possible to trace the benefits of care to specific aspects of the total care package. More variation exists among the results of studies evaluating special pro- grams, although the majority show that prenatal care is associates! with improved birthweight. Those special programs that have shown positive impact on birthweight usually offer prenatal care that goes beyond more routine services to include flexible combinations of education, psychosocial and nutrition services, and certain clinical interventions such as careful screening for medical risks and a rapid response to the first signs of early

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20 labor. The successful projects also offer a package of services that often is carefully defined and describec! in written standards. The limitecl impact of prenatal care suggested by some of the special programs may result from the fact that the care was not organized to address what is now known about the causes and risks of Tow birthweight. For example, the care may not have focused on such factors as smoking reduc- tion, adequate weight gain, reducing alcohol and other substance abuse, patient and provider education about prevention of prematurity, or specific meclical risks associated with low birthweight, such as bacteriuria. Effect of Prenatal Care on Health Care Expenditures The economic impact of prenatal care and other strategies to recluce low birthweight is difficult to evaluate because adequate cost information is rarely available. Nevertheless, informed public policy requires consideration of the costs as well as the benefits of proposed health promotion strategies. The committee found that while it was not possible to complete a formal cost-effectiveness analysis of each of the strategies it recommended to reduce Tow birthwei~ht, it was possible to estimate some of the financial imnlica ~ ~ 1 ~ r .. ~ ... . . . . . . ~ . . . . . lions or providing prenatal services to certain groups of hlgh-rlsk pregnant women. The committee defined a high-risk target population of women with less than a high school education anc! on welfare, who often do not begin prenatal care in the first 3 months (trimester) of pregnancy. The current low birth- weight rate in this group is about Il.5 percent. The committee estimated the increased expenditures that would be required to provide routine prenatal care to all members of the target population from the first trimester to the time of delivery. These expenditures were compared with savings that could be anticipated through a decreased incidence of low birthweight resulting from the improved utilization of prenatal care by the target population. These savings were estimated for a single year and consisted of initial hospitalization costs, rehospitalization costs, and ambulatory care costs as- sociated with general illness. The many assumptions that shaped these calculations are detailed in the report. The analysis showed that if the expandect use of prenatal care reduced the low birthweight rate in the target group from Il.5 percent to only 10.76 percent, the increased expenditures for prenatal services would be approxi- mately equal to a single year of cost savings in direct medical care ex- penditures for the low birthweight infants born to the target population. If the rate were reduced to 9 percent (the 1990 goal set by the Surgeon General for a maximum low birthweight rate among high-risk groups), every addi- tional dollar spent for prenatal care within the target group would save $3.38 in the total cost of caring for low birthweight infants requiring expensive medical care. The committee emphasizes that net savings in government expenditures is a limited criterion. A society concerned with the health and productivity of all its citizens might well choose to recluce low-weight births through actdi- tional investments in prenatal care or other approaches even if the budgetary outlays were to exceed savings.