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27 be learner! from existing experience with the regionalization of perinatal services; (3) how to make state and national data systems more useful in assessing unmet need for prenatal services ancI, more generally, in monitor- ing the impact of various maternal and child health programs; and (4) how to ensure that prenatal care is financed ad equately in times of cost containment, when preventive services often lose the competition for dollars. IMPROVING THE CONTENT OF PRENATAL CARE Participation in conventional prenatal care programs is associated with a reduced incidence of low birthweight. The committee believes, however, that enhancing the content of prenatal care could increase its contribution to the development of healthy infants. This section focuses on ways to strengthen prenatal care for all women, for women at elevated risk of pre- term delivery, and for women at elevated risk of intrauterine growth retarda- tion (lUGR). It also examines interventions closely associated with prenatal care that may help to reduce low birthweight, inclucling smoking reduction programs, nutritional services, and stress alleviation approaches. Finally, recommendations are made for specific actions on content of care issues by the federal government and by professional societies representing the major maternity care providers. Revisions In Care For All Pregnant Women The committee has identified seven components of the prenatal care offered to all pregnant women that merit increased emphasis in the effort to improve pregnancy outcome generally and to prevent preterm delivery and {UGR in particular. 1. Establishing Specific Goals Greater efforts to organize prenatal care around explicit goals can help focus the attention of the patient on the purposes of the prenatal visits and engage her more in her own care. The process of establishing goals also can help the practitioner to structure appropriate interventions and to consider the combination of prenatal serv- ices that should be provided to each pregnant woman. Defining the prevention of Tow birthweight as a major goal of prenatal care may require adjustments in clinical practice. For example, reducing the risk of prematurity or JUGR may require more emphasis on screening and counseling early in pregnancy. At present, prenatal care seems particularly oriented toward the prevention, detection, and treatment of problems that are manifested in the third trimester, particularly preecIampsia thus the emphasis on blood pressure monitoring, screening for proteinuria, attention to possible eclema, and increased frequency of prenatal visits toward the end of pregnancy. By contrast, the goal of preventing low birthweight requires additional attention during the first and second trimesters especially, to screening, diagnosis, and treatment, as early as possible, of conditions that predispose to preterm labor or lUGR, such as smoking and poor nutritional status. Many of the other aspects of prenatal care outlined below also merit attention early in pregnancy, such as the education topics.

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28 2. Risk Assessment Prenatal care should include formal identification anct evaluation of risk. This should be a dynamic process that begins at the first visit and is attentive to developing problems throughout pregnancy. Risk assessment can help to increase the flexibility of prenatal care, which is especially important for women in socially disadvantaged hi~h-risk shrouds: 1 , 1 ~ --a ~ ~-~---~ Or . . ~ . ~ . . . set packages of prenatal care often do not address their multiple problems. It can also help ensure that certain problems and risk factors are both detected and managed properly. 3. Pregnancy Dating Accurate dating of pregnancy is a cornerstone of good prenatal care. Without it, a clinician is less able to detect intrauterine growth retardation, to determine if labor is premature and the extent of the prematurity, or to avoic! accidental prematurity following labor induction or an elective cesarean section. The minimum data required to determine gestational age include the date of the last menstrual period, uterine size by pelvic exam during the first trimester, the time of quickening, the first time fetal heart tones are heard without amplification, and serial fundal height measurements after 20 weeks gestation. 4. Ultrasound Imaging A federal consensus development conference in 1984, sponsored jointly by the National Institutes of Health and the Food and Drug Administration, concluded that available data do not support routine ultrasounc! examination of all pregnancies, but identified almost 30 specific situations in which ultrasound is useful.18 Among these are many indica- tions relevant to the prevention of low birthweight. For example, when a uterine size/ciate discrepancy occurs, ultrasound can help establish gesta- tional age. 5. Detection and Management of Behavioral Risks Prenatal care should in- clude explicit attention to detecting and managing behavioral risks associ- ated with low birthweight, especially smoking, nutritional inadequacies, and moderate-to-heavy alcohol use. In many settings, intervention options to overcome these problems are limited to physician or nurse counseling; in others, more formal programs are available on a referral basis. 6. Prenatal Education Health education for women who are pregnant or contemplating pregnancy should be expanded to include greater emphasis on behavioral risks in pregnancy, early signs and symptoms of pregnancy complications such as preterm labor, the role that prenatal care plays in improving the outcome of pregnancy, and related topics cletailed in the main report. Unfortunately, prenatal care education and counseling services are often inadequate, particularly for high-risk groups. Problems that may interfere with effective education of pregnant women include the short time typically scheduled for each prenatal visit, third-party reimbursement policies that pay for diagnostic and therapeutic procedures but ignore provider costs related to patient education, and lack of patient-education interests and skills on the part of many physicians. in many settings, nurses and relatecl person- nel may be more appropriate than physicians as providers of prenatal educa- tion. Childbirth education classes have not been shown to have an impact on the incidence of low birthweight, probably because they usually begin in the third trimester of pregnancy and focus primarily on labor and delivery. To

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increase their role in the pre- vention of low-weight births, these classes should begin earlier, place greater empha- sis on the prenatal period and the risk factors described above, and make a greater effort to enroll women from lower socioeconomic groups. 7. Health Care System Fac- tors Prenatal care providers should organize their pro- grams to manage a wider variety of patient problems and risk factors than is usual- Ty possible in many prenatal care settings, particularly those in the private sector. Nutritional counseling, psy- chosocial counseling, strate- gies to modify smoking and other health-compromising behaviors, and related services shouIc! be pro- vided directly or through a well-organizecl referral system. In adclition, care should be providecT in a comfortable atmosphere that underscores the im- portance of two-way communication patients should receive full answers to questions about their pregnancies anct should be encouraged to report relevant symptoms or problems. At_ - __ ~ __ __ __ - __- Prenatal Care for Women at High Risk of Preterm Delivery Information on the causes of Tow birthweight and the risk factors associ- atecl with it has led to the development of several innovative programs designee! to prevent preterm delivery. Those described in the committee's report include the March of Dimes Birth Defects Foundation's Multicenter Prevention of Preterm Delivery Program, which originated at the University of California at San Francisco; the I os Angeles Prematurity Prevention Program, implemented in selected health centers that provide prenatal care for the Harbor-UCLA Medical Center; and the French Prematurity Preven- tion Program, which started in the early 1970s in Haguenau, France. Preliminary data from these and other programs suggest several enrich- ments to basic prenatal care that may increase the likelihood) of full-term births to women at high risk of preterm delivery: repeated risk assessments; expanded patient education; and increased provider education. A woman who is at higher than average risk of preterm labor may benefit from repeated risk assessment as her pregnancy proceeds. In particular, women who have been defined as high risk because of a previous preterm

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30 birth or mid-pregnancy loss may require additional cervical assessments in the second half of pregnancy to check for early signs of dilatation or efface- ment. The committee is aware that the value and risks of repeated pelvic examinations in later pregnancy have not been clearly assessed. Women at elevated risk of preterm delivery should also be offered special education about the factors associated with prematurity; the importance of early detection of the symptons of preterm labor/ such as bleeding and periodic contractions; how to detect mild uterine contractions and how to differentiate normal contractions that often occur throughout pregnancy from those signaling early labor; and what to do when the signs and symp- toms of preterm labor appear, including how to contact an obstetric care provider for consultation and help. Efforts to arrest preterm labor (such as use of tocolytic drugs, clescribed below) hinge on its early detection and prompt management. High-risk women also should be taught to identify and lessen events in their daily lives, such as physical stress and strenuous exercise, that can trigger uterine contractions, which in turn might lead to preterm labor. The research data supporting such advice are still tentative, but common sense and clinical judgment support such caution. To complement patient education, provider education should include increased emphasis on the importance of being receptive to patients' com- plaints, some of which may indicate early signs of preterm labor; the uses of hospitalization for women with suspected preterm labor; and the various approaches available for arresting true preterm labor, such as tocolysis. Tocolysis involves the use of specific drugs to inhibit preterm labor. The one such agent licensed for use in the United States is ritodrine hydrochIor- ide. Widespread experience with tocolysis indicates that it can be beneficial in some individual cases of threatened preterm labor, but that the current generation of tocolytic drugs does not offer a long-term solution to the problem of prematurity. Some patients with preterm labor have medical or obstetric complications that caution against the use of tocolytic drugs, and in ~ ~ , ~ .. .. . 1. ~ .1 ~ . . . r .1 .1 ~ . some situations Delivery may ne in the nest interests or tne mother or fetus. Important side effects can follow the use of tocolytic agents; rarely, complica- tions may be life-threatening or even fatal. The number of cases in which tocolytic intervention is successful would probably increase if patients and providers were better informed about the early signs and symptoms of preterm labor, the vital importance of early diagnosis, and the appropriate use of tocolytic drugs. Currently, only about one-third of pregnant patients who arrive at the hospital in preterm labor are suitable candidates for this form of therapy. Prenatal Care for Women at High Risk of Intrauterine Growth Retardation Many of the risk factors linked to preterm labor also are associated with lUGR; thus, some aspects of prenatal care that help to avoid one type of low birthweight also may help prevent the other. For example, careful risk assessment is as important for lUGR detection and treatment as it is for prevention of prematurity. Unfortunately, the data available to suggest new clinical directions for

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31 TUGR reduction are more limited than those for preterm delivery. The literature suggests simply that clinicians caring for pregnant women at elevated risk of JUGR should place extra emphasis on: reduction of behavioral risks such as smoking and alcohol use; nutritional surveillance and counseling-maternal preconception weight and weight gain during pregnancy, especially during the third trimester, are important determinants of birthweight; and early diagnosis and effective management of JUGR through accurate assessment of gestational age ancT fetal growth anc! maturity; ultrasonogra- phy can help in meeting such goals. Programs Complementary to Prenatal Care Because many of the risks associated with low birthweight have a be- havioral basis, the committee examined selected interventions designed to reduce these risks, including smoking reduction strategies and nutritional intervention programs such as the Special Supplemental Food Program for Women, Infants and Children (WIC). The committee also evaluated stress and fatigue abatement approaches, although the evidence that these factors contribute to low birthweight is controversial. The interventions reviewed are not, strictly speaking, components of prenatal care, but they should be adjuncts to more routine prenatal services. Smoking Reduction The committee urges that efforts to help women stop or reduce smoking in pregnancy become a major concern of obstetric care providers. About20 to 25 percent of women who smoke at the beginning of pregnancy quit on their own at some time during the 9 months. Controlled studies suggest that aggressive intervention programs can encourage an to an n~rr~ntmor~ to stop. 19 Several themes derived from the literature on smoking intervention pro- grams can aid practitioners in establishing effective strategies: counseling by a woman's physician or other primary clinician appears to be among the most effective intervention strategies for the pregnant smoker group counseling appears to be less effective; 1 -of a- --r -~ ~~ i-- social support appears to be a critical factor in changing smoking behavior spouses or partners anc} other family members should be in- volved in intervention efforts; smoking reduction deserves high priority, but prenatal care providers should be reasonable in their expectations of the pregnant woman she is probably being asked to make many changes in her life at a time when she may be unusually tired and anxious about a range of sexual and social changes associated with pregnancy and planning for a new baby; the mass media can play a motivating and reinforcing role in encourag- ing changes in smoking habits, but are probably insufficient as the sole approach. Cigarette labels that explicitly warn of the dangers of smoking during pregnancy should supplement other public information strategies; and

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32 research on smoking and pregnancy should receive high priority important topics include how to structure interventions to reach specific high-risk groups, the motivations of women who do stop successfully during pregnancy, the role of social supports such as the spouse, and how to encourage continuation of nonsmoking behavior after delivery. Nutritional Intervention: WIC The data on nutrition and pregnancy outcome support the view that nutritional assessment and services should be major components of high- quality prenatal care, especially for women at elevated risk of JUGR. Accord- ingly, the committee examined the value of the Special Supplemental Food Program for Women, Infants and Children (WIC), which provides one of the principal data sets demonstrating the importance of nutrition to birthweight and represents a major public investment in the nutritional well-being of women and children. WIC is a three-part intervention program involving supplemental food, nutritional counseling, and close ties to prenatal services for nutritionally and financially high-risk women. Evaluation studies have shown that WTC participation is associated with improved pregnancy out- come, including increased birthweight among babies of participating women.20 21 The results also seem to indicate that longer periods of partici- pation in the program during pregnancy (i.e., more than 6 months) are associated with greater weight gains.21 Based on such studies and others reviewed in the main report, the commit- tee recommends that nutritional supplementation programs such as WIC be part of a comprehensive strategy to reduce the incidence of low birthweight among high-risk women and that such programs be closely linked to prena- tal care. Stress and Fatigue Reduction A variety of approaches have been organized to reduce the amount of stress experienced by pregnant women. Some are concerned primarily with physical stress and fatigue, others more with psychosocial and emotional stress. The prematurity prevention program in France, mentioned earlier, emphasizes reduction in physical stress for women with several risk factors (especially a history of preterm delivery, incompetent cervix, or a particularly strenuous life-style). These women may be advised to take a leave of absence from their jobs or get additional help at home. The prematurity prevention program at the University of California at San Francisco addresses psychosocial and physical stresses simultaneously. Through a continuing education program, nurses are taught to recognize 1 ~ O ~ O excessive fatigue or anxiety in their maternity patients and to help the women find solutions to their problems. High-risk patients also receive psychological support during pregnancy from a member of the "Preterm T abor Support Group," which consists of other women who have experi- enced preterm labor. Another potentially important stress reducing intervention is maternity leave. The patchwork arrangement in this country of sick leave, disability

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33 leave, leave without pay, and other leave categories is not adequate to provide job security for pregnant women and new mothers who participate in the labor force. The committee recognizes that revision of maternity policies is a complicated issue, but suggests that more adequate maternity leave, particularly for certain high-risk women, could contribute to a reduc- tion in low birthweight, among other benefits. At a minimum, labor unions, women's groups, and health professionals should explore this issue. Encouraging Change in Prenatal Care To encourage the provision of improved, more flexible prenatal services t-~ Id; ~_~ ~ l ^ Ilk r [ ~+. . ~] 1 ~1 ~1 _ _ ( 1 _ _ _ 1_ ~ 1 ~. . ~1 1 ~ al any But wull`~l aL IllgI! rick or low oIrlnWel~nt tile rommitt~P rP~m- mends four specific strategies: Tl~ ~ I: ~ _ 1 ~ ~ _ _ L_ _ _ I 1_ _ d ~^ ~-^ ~-^4b~ ~ ~- ~11 Lll L1 ~ L= ~1 ~11 ~ - ~= ~ ones Nat represent the principal maternity care providers should carefully review the suggestions made by the committee regarding prenatal care to determine whether their general guidelines for clinical practice should be revised and enriched accordingly. The Division of Maternal and Child Health (DMCH), in concert with both consumer and professional groups concerned with prenatal care, should define a model of services to be used in publicly financed facilities that provide care to pregnant women. This model should be updated and revised frequently to incorporate new knowledge and experience, and should not be used in a way that discourages research on improved approaches to prenatal care. - The professional societies of the major maternity care providers should undertake programs to educate their members about the prenatal care issues highlighted by the committee. Suggestions for continuing education strate- gies are outlined in the complete report. Third-party reimbursement policies should reflect the common need of 1~: ~1 ~i: _ 1 ~ _ _ _ . . . ~ An,, ..^ .~ ~ . ~ .~ ~ ~ en, nlgn-rlsK women tor more intensive prenatal services, the importance of prenatal care being tailored to the needs of individual women and thus variable in its content, the value of counseling and education to reduce behavioral risks such as smoking, and the importance of ancillary services such as transportation to health care facilities. The federal model of prenatal care should emphasize these themes; and labor unions, businesses, and other organizations should incorporate them into negotiations over health insurance benefits. Research Needs ~, ~ ~ ~ _ An. . ~ . Major progress in reducing low birthweight will require a far more soph- ishcated understanding of prenatal care content than now exists. Research on the content of prenatal care should be a high funding priority for founda- hons, public agencies, and institutions concerned with improving maternal and child health. This research should focus on three major areas: (~) descrip- tion and analysis of the current composition of prenatal care, (2) assessment of the efficacy and safety of numerous individual components of prenatal care, and (3) evaluation of certain well-defined combinations of prenatal care interventions designed to meet the widely varied needs and risks among pregnant women.

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34 A.... .... ................ ................ Current Prenatal Care ... ........ .......... The Assistant Secretary for Health should take the lead in organizing activities to increase our knowledge of current prenatal care practices. Exist- ing surveys conducted by the National Center for Health Statistics could include a special emphasis on prenatal care content. Consumer experience with prenatal care should be analyzed and the professional societies of the major maternity care providers should be consulted about ways to survey their members regarding various content issues. in some instances, direct studies of provider practices may be necessary. Individual Components of Care During its study, the committee compiled a long list of research topics involving specific interventions in prenatal care. They are listed in the full report and span both clinical topics and environmentaLbehavioral topics. Combinations of Interventions Both public and private institutions should support studies to assess the effectiveness of well-defined combinations of prenatal interventions in reducing low birthweight and improving infant health generally. In particu- lar, these studies should assess the merits of different prenatal care strategies for women at elevatect risk of prematurity or lUGR. Too often, research on prenatal care has been oriented toward the broad question of whether it improves pregnancy outcome. The appropriate goal now is to identify the components and combinations of prenatal services that are effective in reducing specific risks for well-defined groups of women.