prenatal care; counseling and offering HIV testing in prenatal care; acceptance of prenatal HIV testing; offering, accepting, and complying with ZDV treatment; and provision of quality health care for HIV-infected women.

As indicated in Chapter 4, to successfully reduce perinatal HIV transmission, HIV-infected women would ideally be identified early in pregnancy. Late or no prenatal care is thus a significant barrier to identification and treatment of HIV-infected pregnant women.

From 1970 to 1995, the percentage of women in the United States receiving prenatal care in the first trimester of pregnancy steadily increased from 68.0% to 81.3%, and the percentage of women receiving late (i.e., at seven to nine months gestation) or no prenatal care declined from 7.9% to 4.2% (NCHS, 1997). Relatively few women receive no prenatal care (1.7% in 1992), but rates increase with parity, are higher in African-American women, and are highest in large cities. In 1992, as many as 8.5% of women living in the largest American cities (i.e., the 22 urban areas with populations of 500,000 or more residents) received no prenatal care. Among African-American urban residents, 11.7% had received no prenatal care (compared to 7.0% of white urban women), but rates are over 20% in some urban areas (for example, 22.1% and 20.7% in Manhattan and Philadelphia, respectively) (DHHS, 1992). This trend is worrisome because HIV infection in women tends to be concentrated in large urban areas in the Northeast.

The prenatal care patterns of HIV-infected pregnant women have been assessed in at least three studies. Among the 1,311 HIV-infected pregnant women identified in CDC's State Enhanced Pediatric HIV Surveillance Program (STEP) in four states (New Jersey, South Carolina, Michigan, and Louisiana) from 1993 to 1996, 14% had no prenatal care, and another 23% started care in their third trimester. As many as 35% of drug using, HIV-infected women had no prenatal care (Appendix D; CDC, 1998f). In a study of HIV-infected pregnant Medicaid recipients giving birth from 1985 to 1990, 90% had initiated prenatal or HIV care by 34 weeks' gestation, but only 50% had initiated care by 14 weeks. Fourteen percent of these women received no care until the last few weeks of pregnancy (Turner et al., 1997). Similarly, 14% of HIV-infected women in several counties in Texas received late or no prenatal care (Shakarishvili et al., 1996). These studies would suggest that roughly 15% of HIV-infected women receive no prenatal care.

PHS guidelines recommend that all pregnant women in the United States be offered and encouraged to accept voluntary HIV antibody testing early in pregnancy (CDC, 1995b). Some states go further, requiring that all women in prenatal