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Chapter 1 Who Obtains Insufficient Prenatal Care? Depending on the measure used, between one-fourth and one-third of all pregnant women in the United States do not obtain early, continuous prenatal care. Women in certain sociodemographic groups and in certain geographic areas are significantly less likely than others to secure care, and in recent years, use of prenatal care has actually declined among some groups. Relying primarily on national vital statistics, this chapter presents data on these correlates and trends, focusing in particular on women who receive little or no care, because such minimal care is strongly associated with poor pregnancy outcomes. It begins with a brief discussion of terminology and methods of measuring prenatal care and then describes current patterns of use, analyzes the relationships among demographic risk factors, and presents trends in the use of prenatal care since 1969. TERMINOLOGY AND MEASURES No single specification of the content of prenatal care is unanimously accepted by public health authorities, health care providers, or researchers. The American College of Obstetricians and Gynecologists (ACOG) and a joint working group of representatives from ACOG and from the American Academy of Pediatrics have discussed the goals and content of prenatal care in some details 2 however, and the Expert Pane! on the Content of Prenatal Care ancI the Preventive Services Task Force (both housed within the U.S. Department of Health and Human Services) promise adclitional 26

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WHO OBTAINS INSUFFICIENT PRENATAL CAM? 27 guidance in the future. In the absence of an agreement on the content of prenatal care and because many of its components are difficult to measure, most research on the effectiveness of prenatal services focuses on quantity of care received (such as number of prenatal visits). Prenatal care differs from other types of health care in the measures used to understand its impact on health outcomes. Most studies of the effectiveness of medical care examine provider actions for example, did the physician take an adequate history, order the appropriate tests, and conduct the right procedures? By contrast, studies of the role of prenatal care in pregnancy outcome usually examine consumer actionsfor exam- ple, ctid the pregnant woman initiate care early, and how many visits did she make? It is unclear why in the field of prenatal services the emphasis is on consumer rather than provider behavior. Exceptions to this method of measuring prenatal care include the work of Morehead, Donaldson, and Seravalli in 19713 and, more recently, Hughey in 1986.4 It is also important to note that various efforts to lower maternal mortality in past years have focused on provider behavior during the prenatal period. Three measures of the quantity of prenatal care are widely used: (1) the number of visits made throughout pregnancy (frequency), (2) the trimes- ter or month in which care began (timing), and (3) an index relating the frequency and timing of visits to gestational age. This last measure is the basis of the widely used Kessner index,5 in which a woman's prenatal care is classified as "adequate" if it begins in the first trimester and includes nine or more visits for a pregnancy of 36 or more weeks; "intermediate" if it begins in the second trimester or includes five to eight visits for a pregnancy of 36 or more weeks; or "inadequate" if it begins in the third trimester or includes four or fewer visits for a pregnancy of 34 or more weeks. All three of these measures tacitly acknowledge the schedule of prenatal visits recommended by ACOG: care beginning as early in the first trimester of pregnancy as possible, with additional visits every 4 weeks for the first 28 weeks of pregnancy, every 2 to 3 weeks for the next 8 weeks, and weekly thereafter until delivery. Such a schedule yields about 12 visits for a 39-week pregnancy, 13 for a 40-week pregnancy, and 14 for a 41-week pregnancy. All three measures have two major limitations. First, none includes a precise definition of a prenatal visit. A visit for a pregnancy test only, for example, should not be equated with a prenatal care visit, but anecdotal reports suggest that these two distinct events can be confused by women themselves and commingled in data on use of prenatal care. Second, the measures depend either on a woman's recollection of her prenatal visits or on data contained in her medical record. Both sources can be flawed. For example, if a woman changes her source of care during pregnancy, only

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28 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS the date when she started care at the site used immediately before delivery may be noted in her medical records. If these same records are used to complete the birth certificate the source of data on which most research in this area is based carlier prenatal visits will be ignored. The questionable accuracy of birth certificates is substantiated by a study of the 1972 National Natality Survey, in which the number of prenatal visits listed on birth certificates was compared with survey data. Perfect agreement was found in only 16 percent of the cases.6 In another study, Land and Vaughan reviewed Missouri birth certificate data for 1980 and found that hospitals that obtained information on prenatal care exclusively from the mother reported earlier prenatal care and more visits than those using the prenatal record only or a combination of the prenatal record and information from the mother.7 Another limitation of birth certificate data is that not all states request information about ethnic origin or the mother's marital status.* Despite such problems, birth certificates remain the best generally available source of data on participation in prenatal care. In particular, they can be used to compare patterns of use across states and populations, and they facilitate analysis of trends. Each of the three measures also has unique limitations. Counting the number of prenatal visits, while appealing in its simplicity, ignores the distribution of those visits over the pregnancy. The recommended ACOG schedule speaks as much to the timing of prenatal visits as to their absolute number. In particular, counting visits obscures the relationship between prenatal care and preterm delivery. Even if they follow the recommended prenatal schedule, women who deliver prematurely will obviously have fewer prenatal visits than women who deliver at full term. Unless a statistical adjustment is made for length of gestation, the association of preterm delivery with fewer prenatal visits may appear causal, when, in fact, it probably is not. The second measure, based on the reported date of the first prenatal visit, emphasizes the recommendation that care should begin "early," in the first trimester of pregnancy. Generally, care beginning in the second trimester is referred to as "delayed," and care deferred until the last trimester is termed "late." Although this measure overcomes some of the problems that the frequency index presents, it does not address the fact that early care does not necessarily mean continuous care. For example, a woman may register early in pregnancy to help arrange hospitalization for delivery but not appear again until the third trimester. Despite this shortcoming, the time-of-onset measure is commonly used because the data needed to compute it are widely available. *The 1989 revision of the U.S. Standard Certificate of Live Birth, overseen by the National Center for Health Statistics, recommends several changes that, if adopted by all states, should improve analyses of the use and effectiveness of prenatal care and of interstate differences.

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WHO OBTAINS INSUFFICENT PRENATAL CARE? 29 The third method, primarily the Kessner index, provides a more precise, multidimensional measure of prenatal care; however, it is complicated to compute, and for many births data are lacking on one or more of the three variables that make up the index (month in which prenatal care was begun, number of visits, and gestational age). A number of modified versions of the Kessner index have been proposed, including one by Kotelchuck.8 The measure used most often in this volume is the trimester in which prenatal care was begun, using the terms "early, delayed, and late," as just defined. The terms "adequate, intermediate, and inadequate" are Kessner index phrases, also defined above. The term "insufficient" is used as a general description of care that is neither adequate nor ~n~atea early In pregnancy; similarly, "sufficient" is used as a general label to describe care that begins early in pregnancy and is sustained until delivery. A final point: Where vital statistics data are used in this chapter, the data technically refer to infants rather than mothers, because each record is based on an individual birth certificate. However, since multiple births are relatively infrequent (21 per 1,000 live births in 1985) and few women have more than one birth in any year, the terms "women," "mothers," and "births" are often used interchangeably. CURRENT PATTERNS OF USE* ,- . 1 1 According to 1985 birth certificate data for the 50 states and the District of Columbia, 76.2 percent of all infants were born to women who obtained early prenatal care, 18.1 percent to women who delayed care, 4.0 percent to women who obtained care late, and 1.7 percent to mothers who had no prenatal care at all (Table 1.11. In absolute numbers, of the approximately 3.8 million babies born in the United States in 1985, about 2.8 million were born to women who began prenatal care early in pregnancy, about 663,000 to women who delayed care, some 150,000 tO women who obtained care late, and about 61,000 to women who had no prenatal care at all (Table 1.21. When vital statistics are analyzed to determine rates of adequate care rather than trimester of onset, a slightly different picture emerges. Hughes et al. found that in 1985 only 68.2 percent of all women obtained adequate care, 23.9 percent had an intermediate level of care, and 7.9 percent of all women had inadequate care.9 The following sections describe women's use of prenatal care as measured by six sociodemographic factors: race or ethnic origin, age, education, birth order, marital status, and income. *All data in this section are vital statistics compiled by the National Center for Health Statistics, unless otherwise noted.

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30 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 1.1 Month of Pregnancy in Which Prenatal Care Was Begun (Percent), by Age and Race, United States, 198S Month Care Begun (%) Age 1-3 4-6 7-9 None White Under 15 38.3 39.8 15.1 6.9 15-19 56.8 32.3 8.0 2.9 20~24 74.7 19.3 4.3 1.6 25-29 85.5 11.4 2.2 0.9 30~34 87.5 9.9 1.8 0.7 3~39 84.5 12.0 2.4 1.1 40+ 75.1 18.2 4.5 2.2 Total 79.4 15.8 3.4 1.3 Black Under 15 34.4 46.1 13.6 5.9 15-19 47.3 38.3 10.0 4.4 2~24 60.1 29.3 7.1 3.5 25-29 70.3 22.3 4.7 2.7 3~34 73.2 20.1 4.1 2.6 35-39 71.2 21.5 4.4 3.0 40+ 63.5 26.8 5.7 4.0 Total 61.8 28.2 6.7 3.4 All Races Under 15 36.0 43.5 14.2 6.3 15-19 53.9 34.1 8.6 3.4 2~24 71.7 21.4 4.9 2.0 2~29 83.1 13.1 2.6 1.1 3~34 85.5 11.4 2.2 1.0 35-39 82.4 13.4 2.8 1.3 40+ 72.9 19.8 4.8 2.5 Total 76.2 18.1 4.0 1.7 SOURCE: National Center for Health Statistics. Advance report of final nasality statistics, 1985. Monthly Vital Statistics Report, Vol. 36, No. 4 Suppl. DHHS Pub. No. (PHS)87- 1120. Hyattsville, Md., 1987. Racial and Ethnic Subgroups Racial disparities in the use of prenatal care are substantial (Table 1.1~. In 1985, black women were far less likely than white women to begin care early and twice as likely to receive late or no care. In absolute numbers, almost 140,000 white infants and almost 60,000 black infants were born to

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? 3 women who had late or no prenatal care (Table 1.21. The higher rates of late or no care among black women are probably due to the greater concentration in this population of several risk factors associated with insufficient prenatal care: limited education, being unmarried (in 1985, 11 percent of white births were to unmarried women versus 57 percent of black births), and, in particular, poverty. TABLE 1.2 Month of Pregnancy in Which Prenatal Care Was Begun (Number), by Age and Race, United States, 198S Month Care Begun (no.) Unknown Age 1-3 4-6 7-9 None Total (no.) (no.) Mite Under 15 1,511 1,569 595 272 4,101 154 15-19 176,527 100,276 24,755 9,130 318,725 8,037 20-24 654,059 169,405 37,860 14,393 894,195 18,478 25-29 836,861 112,063 21,594 8,539 997,233 18,176 30~34 498,630 S6,642 10,345 4,125 580,398 10,656 35-39 143,587 20,364 4,153 1,868 173,681 3,709 40+ 16,853 4,089 999 493 23,040 606 Total 2,328,028 464,408 100,301 38,820 2,991,373 59,816 Blac1: Under 15 1,947 2,607 767 335 5,860 204 15-19 61,324 49,716 12,909 5,722 134,270 4,599 20-24 120,704 58,862 14,197 6,988 207,330 6,579 25-29 103,869 32,851 6,974 3,960 152,306 4,652 30~34 55,355 15,176 3,094 1,967 78,129 2,537 35-39 17,986 5,438 1,098 746 26,216 948 40+ 2,495 1,053 224 157 4,082 153 Total 363,680 165,703 39,263 19,875 608,193 19,672 All Races Under 15 3,547 4,283 1,398 623 10,220 369 15-19 244,723 155,073 39,129 15,364 467,485 13,196 20~24 799,206 238,463 54,921 22,197 1,141,320 26,533 25-29 978,340 15i,195 31,061 13,202 1,201,350 24,552 30-34 582,791 77,647 14,913 6,549 696,354 14,454 35-39 172,441 28,120 5,826 2,814 214,336 5,135 40+ 20,849 5,669 1,367 718 29,496 893 Total 2,801,897 663,450 148,615 61,467 3,760,561 85,132 SOURCE: National Center for Health Statistics. Advance report of final nasality statistics, 1985. Monthly Vital Statistics Report, Vol. 36, No. 4 Suppl. DHHS Pub. No. (PHS)87-1120. Hyattsville, Md., 1987.

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32 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 1.3 Percentage of Babies Born to Women Obtaining Early and Late or No Care, by Hispanic and Non-Hispanic Origin, Various Reporting Areas, 1978, 1982, and 1985 Hispanic Non-Hispanic Central Care Puerto and South Received Mexican Rican Cuban American Other Total White Black Total 1 978a Early 58.7 47.7 75.9 51.5 67.0 57.0 80.7 59.1 77.0 Late or none 11.5 19.9 6.5 16.0 8.3 13.1 3.3 10.9 4.6 1 982b Early 60.7 54.5 79.3 58.5 66.0 61.0 81.2 60.1 76.9 Irate or none 12.0 17.2 4.9 13.4 9.3 12.1 3.8 10.5 5.2 l985c Early 60.0 58.3 82.5 60.6 65.8 61.2 81.5 60.5 77.1 Irate or none 12.9 15.5 3.7 12.5 9.4 12.4 4.0 10.7 5.4 SOURCES: aNational Center for Health Statistics. Births of Hispanic parentage, 1978. Prepared by Ventura SJ and Heuser RL. Monthly Vital Statistics Report, Vol. 29, No. 12 Suppl. DHHS Pub. No. (PHS)81-1120. Hyattsville, Md., 1981 (17 states and the District of Columbia reporting). National Center for Health Statistics. Births of Hispanic parentage, 1982. Prepared by Ventura SJ. Monthly Vital Statistics Report, Vol. 34, No. 4 Suppl. DHHS Pub. No. (PHS)85-1120. Hyattsville, Md., 1985 (23 states and the District of Columbia reporting). National Center for Health Statistics. Births of Hispanic parentage, 198S. Prepared by Ventura S) and Heuser RL. Monthly Vital Statistics Report, Vol. 36, No. 11 Suppl. DHHS Pub. No. (PHS)88-1120. Hyattsville, Md., 1988 (23 states and the District of Columbia reporting). Use of prenatal care by mothers of Hispanic origin has been analyzed for the District of Columbia and the 23 states that routinely collect informa- tion on Hispanic births. More than 92 percent of the total U.S. Hispanic population lived in these jurisdictions in 1985, and over 370,000 births to mothers of Hispanic origin were reported. Of these births, the vast majority (95 percent) were listed as being of white race on the birth certificate, two-thirds were to women of Mexican origin, and nearly half (47 percent) were to mothers who had been born in the United States.~ Generally, Hispanic mothers are substantially less likely than non- Hispanic white mothers to begin prenatal care early and are three times as likely to obtain late or no care. Moreover, as Table 1.3 shows, Hispanic mothers as a group are more likely than non-Hispanic black mothers to

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? TABLE 1.4 Percentage of Babies Born to Women Obtaining Early and Late or No Care, for Asian or Pacific Islander, American Indian, White, and Black Subgroups and for All Races, United States, 1985 33 Asian or Pacific Islander Ameri- Care Japa- Hawai- Fili- can All Received Chinese nese fan pino Other Total Indian White Black Races Early 82.3 85.8 70.6 77.2 70.7 75.0 60.3 79.4 61.8 76.2 I ate or 4.2 2.7 6.5 i.6 7.8 6.2 11.5 4.7 10.1 5.7 none SOURCE: Unpublished vital statistics data from the National Center for Health Statistics. begin care late or not at all.* Interestingly, mothers of Cuban background are an anomaly among Hispanic women in their use of prenatal services. They were even more likely than non-Hispanic white mothers to begin prenatal care early in pregnancy, and only 3.7 percent of Cuban mothers in 1985 had late or no care. Such subgroup diversity suggests that the problem of inadequate care among Hispanic women is not due to Hispanic origin per se, but rather to other factors probably income, education, previous experiences with other health care systems, or a combination of the three. Other major U.S. subgroups whose use of prenatal care has been analyzed include American Indian (not including native Alaskans) and Asian or Pacific Islander women (Table 1.4~. Out of 3.8 million births in the United States in 1985, there were about 41,000 to American Indians and 112,000 to Asian or Pacific Islander women. In that same year, Chinese, Japanese, and Filipino women exhibited particularly high rates of participation in care and were less likely than white women to obtain late or no care; Hawaiian women and other subgroups of women in this category (including Indian, Cambodian, Laotian, Vietnamese, Korean, and other Asian or Pacific Islander women) placed between white and black women in the late or no-care category. American Indian women, however, were more likely than either white or black women to obtain late or no care. Use of prenatal care also varies with a pregnant woman's place of birth. For example, two studies of prenatal care use among selected groups in New York City found that recent immigrants were less likely to obtain late *Although Table 1.3 and some others that follow present data for several years in addition to 1985, discussion of trends does not begin until later in this chapter. Here, the focus is on 1985 patterns of use only.

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34 PRENATAL CARE: REACHING MOTHER, ACHING INFANTS or no care than women born in the United States. i2 By contrast, a large follow-back survey of 1986 births in Massachusetts found that foreign- born women were more likely to obtain late or no care than U.S.-born women (24 percent versus 37 percent, respectively).~3 Differences in local health care systems, in the magnitude of language barriers, and in the immigrant populations themselves may account for such variation. Most experts in maternity services believe that recently arrived immigrants are at high risk of obtaining insufficient prenatal care. Age a Timing of entry into prenatal care also varies with the age of the mother (Table 1.19. In general, young mothers are at high risk of obtaining late or no prenatal care, with the greatest risk for the youngest mothers.~4 Adolescent mothers are the age group least likely to obtain early prenatal care and most likely to begin care late or not at all, but there are some interesting variations in utilization between black and white teenage mothers, as shown in Table 1.1. Although white mothers under IS are slightly more likely than black mothers under IS to begin prenatal care in the first trimester, they are also more likely to begin care in the third trimester or not at all. The number of births to these very young women, however, is small 10,220 in 1985. Use of prenatal care among teenagers has also been analyzed using the more refined measure of adequacy. Examining the adequacy of care is particularly appropriate for this group, because teenagers may be more likely than older women to participate in care episodically. Using 1980 National Natality Survey data, one study found that mothers under age 20 were nearly twice as likely to have inadequate care as mothers age 20 to 24 (16.4 and 8.4 percent, respectively).~5 Older mothers, much as teenagers, tend to delay entry into prenatal care (Table 1.1~. Mothers age 40 and over are less likely than mothers age 25 to 39 to begin care in the first trimester and more likely to obtain care late or not at all. This tendency increases as women get older, and women over age 4S become as likely as or more likely than mothers age IS to 19 to obtain late or no care. As for very young teenagers, however, the number of births to older mothers is smallfewer than 30,000 to women age 40 or above in 1985. Education Timing of the first prenatal visit correlates highly with level of educa- tion. In 198S, 88 percent of mothers with at least some college education began care early in pregnancy, compared with S8 percent of mothers who

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? 35 TABLE 1.5 Percentage of Babies Born to Women Obtaining Late or No Care, by Race and Education, United States, 197S, 1980, and 198S Years of Education 1985a l98oa l975b White 0 8 14.1 13.4 13.6 9-1 1 9.6 8.5 8.6 12 3.5 2.9 3.2 13+ 1.5 1.4 1.6 Total 4.0 3.8 4.2 Black 0~8 15.7 15.2 15.8 9-1 1 14.4 12.6 13.3 12 9.3 7.7 9.3 13+ 4.9 4.5 5.8 Total 10.1 9.0 10.9 All Races 0~8 14.7 14.1 14.4 9-1 1 1 1.2 9.8 10.2 12 4.6 3.8 4.2 13+ 2.0 1.9 2.1 Total 5.3 4.8 5.7 SOURCES: aPublished and unpublished vital statistics data from the National Center for Health Statistics. bNational Center for Health Statistics. Prenatal care, United States, 1969-75. Prepared by TaFel SM. Vital and Health Statistics, Series 21, No. 33. DHEW Pub. No. (PHS)78-1911. Washington, D.C.: Government Printing Office, 1978. had less than a high school education.~7 Similarly, the probability that a pregnant woman will obtain care late or not at all decreases steadily as her educational level increases (Table 1.51. Given the strong association between higher levels of education and early enrollment in prenatal care, it is useful to consider the proportion of mothers in various subpopulations who have completed high school. In both 1984 and 198S, 79 percent of all mothers had completed at least 12 years of schooling82 percent of white mothers, 68 percent of black mothers. In 1984, more than twice the proportion of Native American mothers (American Indians and Native Alaskans) as white mothers had less than 12 years of education (38 percent versus 18 percent). Native American mothers were also more likely than black mothers not to have

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36 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 1.6 Percentage of Babies Born to Women Obtaining Late or No Care, by Birth Order and Race, Reporting Areas, 197S, 1980, and 1985 Birth Order l9S5a l98oa l975b White First 4.1 3.8 4.8 Second 4.0 3 5 3 9 Third 5.4 4.5 4.9 Fourth 7.8 6.6 7.0 Fifth+ 13.1 11.3 12.6 Black First 8.8 7.8 9.6 Second 9.4 8.4 10.2 Third 10.6 9.0 10.6 Fourth 12.9 10.6 11.7 Fifth+ 16.5 13.5 13.9 All Races First 4.9 4.6 5.6 Second 4.8 4.4 4.9 Third 6.4 5.5 6.0 Fourth 9.1 7.7 8.1 Fifth+ 14.2 12.8 13.2 SOURCES: aPublished and unpublished vital statistics data from the National Center for Health Statistics. bNational Center for Health Statistics. Prenatal care, United States, 1969-75. Prepared by Taffel SM. Vital and Health Statistics, Series 21, No. 33. DHEW Pub. No. (PHS)78-1911. Washington, D.C.: Government Printing Office, 1978. completed high school.~9 For mothers of Hispanic origin, 21 states (not including California and Texas) reported in 1984 on educational attainment; overall, 4S percent of Hispanic mothers giving birth in that year had not completed at least 12 years of school, with subgroup proportions ranging from S9 percent for Mexican mothers to 22 percent for Cuban mothers.20 Birth Order Obtaining late or no prenatal care is also associated with birth order. In general, the more children a woman has had, the more likely she is to delay care or to seek none at all. In 198S, close to 5 percent of both first and second children were born to mothers who obtained late or no care (Table 1.61. About 6 percent of third births fell into this category, however, and the numbers increased to 9 and 14 percent for fourth and fifth children,

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? TABLE 1.10 Continued 43 State 1 985a 1979a 1975b l969b Tennessee 5.5 5.3 6.8 11.1 Texas 11.0 8.1 9.4 13.1 Utah 3.1 2.6 2.0 3.8 Vermont 3.5 3.4 4.8 7.0 Virginia 4.0 3.4 Washington 4.7 3.6 3.8 4.7 West Virginia 6.1 6.3 8.8 11.5 Wisconsin 3.0 2.7 2.6 4.6 Wyoming 4.3 4.7 5.1 7.1 Total 5.7 5.1 6.0 8.2 SOURCES: aHughes D, Johnson K, Rosenbaum S. Simons I, and Butler E. The Heals of Amenca's Children: Maternal and Child Heals Data Book. Washington, D.C.: Children's Defense Fund, 1988. bNational Center for Health Statistics. Prenatal care, United States, 1969-75. Prepared by Taffel SM. Vital and Health Statistics, Series 21, No. 33. DHEVV Pub. No. (PHS)78-1911. Washington, D.C.: Government Printing Office, 1978. in New York in 198S was roughly three times as likely as a woman in Michigan or Connecticut to obtain late or no care, and a nonwhite woman in New Mexico or New York was three times as likely as a nonwhite woman in Massachusetts to obtain late or no prenatal care. The analyses also show that states with low percentages of mothers obtaining early care also tend to have high percentages of mothers obtaining late or no prenatal care. In 1985, the three jurisdictions with the lowest percentages of women obtaining early prenatal care and the highest percentages of women with late or no care were New Mexico, the District of Columbia, and Texas.36 Even greater variations in levels of prenatal care can exist within states. For example, although New York State as a whole reports that 9 percent of pregnant women in 1985 had late or no prenatal care (Table 1.10), the percentage was about 18 percent in New York City and far higher in some neighborhoods: in the Mott Haven district of the Bronx, more than 50 percent of births in 1985 were to women with no care or care that began in the third trimester.37 Public health authorities and health planners have long recognized that certain communities show particularly poor rates of prenatal care use, and many of the recent state and local initiatives to combat infant mortality (see Appendix A) have included careful "mapping" of areas where inadequate use is prevalent. The maps in Figures 1.2 to 1.S show rates of insufficient prenatal care for various geographic areas. Figures 1.2 and 1.3 are of Wisconsin and a

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~4 DILL If: ~C~G ~O~, FIG ~~ . ~ s _ =1a~o1 Births I\ \ \ \ _ ^ ^ ~:::::~:~:S::::::] ~~:~.~.~.'e's'~'.I :::::::~:~:S:S:S:1 Percentage of Births ~3.0 F:~:!?Ss3~91 3.1 10 5.0 5.110 7,0 ~ ~ ~ 1- _ >10.0 FIGURE 1.1 Percentage of births to women obtaining late or no prenatal care, United Smtes, ~1 races, 1985. SOURCE: Children De~nse Fund. Norm CamUna and deeply, r~ec~e~$ patio of lam or no care and patters of inadequate care in 1985. These maps rheas that rural as wed as urban areas exhibit pocked of insufficient prenatal care. Figures 1.4 and 1.5 present a 1985 geographic profile of late or no registration in prenatal care for the District of Columbia and New Haven, Connecticut. Although each of these maps takes a somewhat idios~cradc approach to defining and displaying geographic variations in use of prenatal care, they electives communicate the simple fact that pockets of need exist and can be pinpointed. Such maps also show that aggregate data, both state and national can obscure the fact that use of prenatal care can be exceedingly poor in some smaller areas. These geographic "hot spots' are perhaps best explained by variations in income levels within states and communizes. ~ noted Barber, low income is among the most important Actors explaining insufficient use of prenatal care. Thus, census track with high concen~abons of low-income individuals are likely to hue high rates of insufficient prenatal care. Other Actors that probably account for these geographic

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? 45 Percentage of Births ~<3.0 .0 town >5.0 .~o Milwaukee FIGURE 1.2 Percentage of births to women obtaining late or no prenatal care, Wisconsin, by county, all races, 1985. SOURCE: Wisconsin Department of Health and Social Services. concentrations of need include local inadequacies in the health care system and transportation problems. These obstacles to care and others are taken up in Chapter 2. TRENDS IN THE USE OF PRENATAL CARE Several special studies3~42 combined with U.S. nasality statistics pub- lished by the National Center for Health Statistics,43 make possible an

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46 it, - - ~ ~ ~ ~- ~ ~ ._ Cal Cal ~ ~ o ~ :z Cal . . _ LL1 . Lo a! Go _ o an Cal .5 - o ,6.,o.'.~o ~~ I-:' ~ / ~ mu. .~) ~ 2- ~-~.~_ no o 5-. o z ~ so ~ ~4 ~ o Cal ~ ._ ._ ._ be ~ .5 .5 o . o ._ 4 - o ~4 of ~ As- .# , . - o CO ._ m - o a) V a' ~ 0 0 0 0 A 4 - o wo4 o of _ a' .e . ~ - ~ no At = - no - ~ Or ; ~ _4 ~ ~ ~ Cal ~ ._ U. _ an

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? - Percentage of Births ~ <5.0 C~ 5.0 to9.9 ~ > 10.0 \~3 47 ~ - ~ ,6 2 ~ 8 / FIGURE 1.4 Percentage of births to women obtaining late or no prenatal care, District of Columbia, by ward, 1985. SOURCE: D.C. Department of Human Services. analysis of trends in the use of prenatal care from 1969 to 1985. Table 1.11 shows steady improvement from 1969 through 1980 in the percentage of births to mothers receiving prenatal care in the first trimester of pregnancy. Since 1980, however, this percentage has remained stable or decreased. Among black women, declines in early use of prenatal care were registered in 1981,1982, and 198S. Table 1.12, which displays rates of late or no care, reveals a particularly troubling trend. There has apparently been an increase since 1980 in the percentage of births to women with late or no prenatal care. Although this trend applies to all races, the increase is more pronounced among black women. In 1981, 8.8 percent of births to black women were in this category; by 1985, 10 percent were. In fact, 198S rates of late or no prenatal care for black women are about the same as those recorded in 1976; improvements in the interim have, in effect, been erased. An analysis of trends in the use of prenatal care between 1970 and 1983 found that early enrollment for black mothers in 1982 was 3.6 percentage points below what it would have been if the 1976 to 1980 trend had continued, and 10.8 percentage points below the expected level based on the 1970 to 197S trend.44

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48 PRENATAL Cal: ACHING MOTHER, ACHING INFANTS Given the size and diversity of this country, it is important to consider whether all states mirror these national trends or whether a few states are responsible for observed changes. Table 1.10 shows use of prenatal care for selected years from 1969 to 1985, based on national data for all 50 states and the District of Columbia. (Although 1969 data are not available from 13 states and in 1975 8 states had not yet begun to collect data on time of entry into prenatal care, general state trends can nonetheless be seen.) There was a clear pattern of improved use of prenatal care on the state level in the early 1970s. All 37 reporting states and the District of Columbia showed smaller percentages of women obtaining late or no care in 197S, as compared to 1969. Most states demonstrated decreases of \ y~ ~~\~ :'=: Percentage of Births c 11.0 [I 11.0to15.0 >15.0 L_ - FIGURE 1.5 Percentage of births to women obtaining late or no prenatal care, New Haven, Connecticut, by neighborhood, all races, 1982-198S. SOURCE: de Andres P. Backus L, Greene M, Pope E, Scholle R. Singleton C, and Triffin E. Targeting the Problems behind New Haven's Infant Mortality Rate. A report of a community project conducted by students at the Department of Epidemiology and Public Health, Yale School of Medicine. New Haven, Ct. Spring 1985.

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? TABLE 1.11 Percentage of Babies Born to Women Obtaining Early Care, by Race, United States, 1969-1985 49 Year White Black Total 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 72.4 72.4 73.0 73.6 74.9 7S.9 75.9 76.8 77.3 78.2 79.1 79.3 79.4 79.3 79.4 79.6 79.4 42.7 44.3 46.6 49.0 51.4 53.9 55.8 57.7 59.0 60.2 61.6 62.7 62.4 61.5 61.5 62.2 61.8 68.5 67.9 68.6 69.4 70.8 72.1 72.3 73.5 74.1 74.9 75.9 76.3 76.3 76.1 76.2 76.5 76.2 SOURCE: Published and unpublished vital statistics data from the National Center for Health Statistics. between 2S and 30 percent, and late or no care decreased by nearly 40 percent in several states between 1969 and 197S. These favorable trends continued into the late 1970s. From 1975 to 1979, all but 7 of the 43 reporting jurisdictions showed continued declines in the percentage of babies born to women who had received late or no care. However, the rate of decline had slowed, and 6 of the 7 states showed an increase. Between 1979 and 1985, the increase in the percentage of women obtaining late or no care evidenced in national statistics was mirrored in states from every region of the country. For example, although the number of women beginning care late or not at all in the District of Columbia dropped by 65 percent between 1969 and 1979, the number increased 43 percent between 1979 and 198S. In Oregon and Indiana, the percentages of women who had no prenatal care or none before the seventh month of pregnancy were greater in 1985 than in any other year since 1975. Maine, Massachusetts, and Utah are states with generally Tow percentages of late or no prenatal care, yet they, too, experienced increases between 1979 and 1985. South Carolina and Florida experienced upward trends of about 30 percent each between 1979 and 1985. Overall, 20 states experienced an increase in the percentage of women who obtained late or no care during

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so PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 1.12 Percentage of Babies Born to Women Obtaining Late or No Care, by Race, United States, 1969-1985 Year White Black Total 1969 6.3 18.2 7.3 1970 6.2 16.6 7.9 1971 5.8 11.6 7.2 1972 5.5 13.2 7.0 1973 5.4 12.4 6.7 1974 5.0 11.4 6.2 1975 5.0 10.5 6.0 1976 4.8 9.9 5.7 1977 4.7 9.6 5.6 1978 45 93 5 4 1979 4.3 8.9 5.1 1980 4.3 8.8 5.1 1981 4.3 9.1 5.2 1982 4.5 9.6 5.5 1983 4.6 9.7 5.6 1984 4.7 9.6 5.6 1985 4.7 10.0 5.7 SOURCE: Published and unpublished vital statistics data from the National Center for Health Statistics. this period, and a dozen more states showed no decrease. The Ingram et al. study of the use of prenatal care between 1970 and 1983 confirms the finding that the trends observed on the national {eve] reflect changes in many states from all regions.45 It is not known what factors account for these disturbing trends, although a number of social, economic, and other changes in the 1980s have been offered as explanations. These include the increase in unem- ployment in the early 1980s and the resulting loss of employer-based health insurance and personal income; the increasing proportion of women of childbearing age living in poverty; and the increasing number of employed individuals who have inadequate or no health insurance, along with the continuing erosion of maternity benefits under private plans. Other reasons include the cutbacks in Medicaid eligibility in the early 1980s and the declining proportion of the poor covered by Medicaid; the increasing proportion of births to unmarried women and the growth in the number of households headed by single women; and the increasingly limited capacity of the health care systems relied on by Tow-income women for prenatal care, caused by funding restrictions and the malpractice squeeze, which is shrinking the pool of obstetric care providers. Many of these issues are discussed in Chapter 2.

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? 51 Other important trends between about 1970 and the mid-1980s include the following: a. The gap between black and white rates of prenatal care use narrowed between 1970 and 1983, although the pace at which it was closing slowed toward the latter half of that interval.46 b. Adolescent mothers were more likely to obtain early care in 198S than they were in 1970. Generally, there has been a decline in late or no care among teenagers; however, the decline has been least for the youngest mothers, and, as among older women, progress has slowed in the 1980's.47 c. As for black women, increasing percentages of some subgroups of Hispanic womenparticularly Mexican womenobtained late or no care in the 1980s (Table 1.31. d. In recent years, there has been virtually no improvement in the proportion of women with little education who obtained late or no care (Table 1.5). e. Between 1970 and 1985, unmarried mothers, particularly unmarried white mothers, exhibited some of the most rapid decreases in late registration for prenatal care (Table 1.79. f. Data from 1975, 1980, and 1985 consistently show that for black women, first births are the least likely to have had late or no prenatal care; for white women, second births are the least likely to fall in this category (Table 1.63. SUMMARY Several interrelated demographic factors put women at risk for insuffi- cient prenatal care: being in a racial or ethnic minority group (especially American Indian, black, and Hispanic), being under 20 (particularly, under 15), having less than a high school education, higher parity, and being unmarried. Geographic analysis also reveals that insufficient use of prenatal care is often concentrated in areas that can be easily identified. All of these risk factors, in turn, are closely related to poverty, which is one of the most important factors consistently associated with insufficient prenatal care. Unfortunately, the steady progress of the 1970s in drawing more women into prenatal care early in pregnancy ended in the 1980s. On the important measure of late or no care, there has actually been a reversal of progress, particularly for black women. REFERENCES AND NOTES 1. American College of Obstetricians and Gynecologists. Standards for Obstetric- Gynecologic Services, 6th ed. Washington, D.C., 1985.

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52 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS 2. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Washington, D.C., 1983. 3. Morehead MA, Donaldson RS, and Seravalli MS. Comparisons between OEO Neighborhood Health Centers and other health care providers of ratings of the quality of health care. Am. J. Public Health 61:1294-1306, 1971. 4. Hughey MI. Routine prenatal and gynecologic care in prepaid group practice. J. Am. Med. Assoc. 256:177~1777, 1986. 5. Kessner DM, Singer J. Kalk CE, and Schlesinger ER. Infant death: An analysis by maternal risk and health care. In Contrasts in Health Status, Vol. 1. Washington, D.C.: National Academy of Sciences, 1973. 6. National Center for Health Statistics. Comparability of reporting between the birth certificate and the National Natality Survey. Prepared by Querec U. Vital and Health Statistics, Series 2, No. 83. DHEW Pub. No. (PHS)80-1357. Washington, D.C.: Government Printing Office, 1980. 7. National Center for Health Statistics. Birth certificate completion procedures and the accuracy of Missouri birth certificate data. Prepared by Land G and Vaughan B. Priorities in Health Statistics: Proceedings of the 19th National Meeting of the Public Health Conference on Records and Statistics, August 1983. DHHS Pub. No. (PHS)81-1214. Washington, D.C.: Government Printing Office, 1983, pp. 263-265. 8. Kotelchuck M. The mismeasurement of prenatal care adequacy in the U.S. and a proposed alternative two-part index. Paper presented at the American Public Health Association annual meeting, New Orleans, 1987. 9. Hughes D, Johnson K, Rosenbaum S. Simons J. and Butler E. The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1988. The definition of adequate care used in these analyses differs slightly from that in the Kessner index: gestational age at which measurement begins is 17 weeks in this modified index versus 13 or fewer weeks in the Kessner index. 10. National Center for Health Statistics. Births of Hispanic parentage, 1985. Prepared by Ventura SI. Monthly Vital Statistics Report, Vol. 36, No. 11 Suppl. DHHS Pub. No. (PHS)88-1120. Hyattsville, Md., 1988. 11. Chao S. Imaizumi S. Gorman S. and Lowenstein R. Reasons for absence of prenatal care and its consequences. New York: Department of Obstetrics and Gynecology, Harlem Hospital Center, 1984. 12. Kalmuss D, Darabi KF, Lopez I, Caro FG, Marshall E, and Carter A. Barriers to Prenatal Care: An Examination of Use of Prenatal Care Among Low-Income Women in New York City. New York: Community Service Society, 1987. 13. Johnson S. Gibbs E, Kogan M, Kapp C, and Hansen OH. Massachusetts Prenatal Care Survey Factors Related to Prenatal Care Utilization. Boston: SPRANS Prenatal Care Project, Massachusetts Department of Public Health, 1987. 14. Hughes D et al. Op. cit., p. 29. 15. The Financing of Maternity Care in the United States. New York: Alan Guttmacher Institute, 1987, p. 45. 16. National Center for Health Statistics, Division of Vital Statistics. Unpublished data, 1984. 17. National Center for Health Statistics. Advance report of final nasality statistics, 1985. Monthly Vital Statistics Report, Vol. 36, No. 4 Suppl. DHHS Pub No. (PHS)87- 1120. Hyattsville, Md., 1987, p. 9. 18. Ibid., p. 8. 19. National Center for Health Statistics. Characteristics of American Indian and Alaska native births, United States, 1984. Prepared by Towel SM. Monthly Vital Statistics Report, Vol. 36, No. 3 Suppl. DHHS Pub. No. (PHS)87-1120. Hyattsville, Md., 1987.

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WHO OBTAINS INSUFFICIENT PRENATAL CARE? 53 20. National Center for Health Statistics. Births of Hispanic parentage, 1985. Op. cit. 21. National Center for Health Statistics. Advance report of final nasality statistics. 198S. Op. cit., table 2, p. 14. 22. National Center for Health Statistics. Prenatal care, United States, 1969-75. Prepared by Taffel SM. Vital and Health Statistics, Series 21, No. 33. DHEW Pub. No. (PHS)78-1911. Washington, D.C.: Government Printing Office, 1978. 23. Singh S. Torres A, and Forrest ID. The need for prenatal care in the United States: Evidence from the 1980 National Natality Survey. Fam. Plan. Perspect. 17:118-124, 1985. National Center for Health Statistics. Advance report of final nasality statistics, 1985. Op. cit., p. 7. 25. National Center for Health Statistics. Births of Hispanic parentage, 1985. Op. cit., p. 9. 26. Singh S et al. Op. cit., p. 121. 27. Ventura SJ and Hendershot GE. Infant health consequences of childbearing by teenagers and older mothers. Public Health Rep. 99:138-146, 1984, p. 144. 28. Placek P. The 1980 National Natality Survey and National Fetal Mortality Survey: Methods used and PHS agency participation. Public Health Rep. 99:111-116, 1984. 29. National Center for Health Statistics. National Survey of Family Growth, Cycle III sample design weighting, and variance estimation. Prepared by Bachrach C, Horn MC, Masher WD, and Shitmizu I. Vital and Health Statistics, Series 2, No. 98. Washington, D.C.: Government Printing Office, 1985. 30. Singh S et al. Op. cit. 31. Unpublished data from the 1982 National Survey of Family Growth, provided by the Family Growth Statistics Branch, Division of Vital Statistics, National Center for Health Statistics, U.S. Public Health Service. 32. Johnson S et al. Op. cit., p. 19. 33. Singh S et al. Op. cit., p. 120. 34. Ibid., p. 123. 35. Ingram DD, Makuc D, and Kleinman IC. National and state trends in use of prenatal care, 1970-83. Am. J. Public Health 76:415-423, 1986, p. 417. 36. Hughes D et al. Op. cit., p. 70. 37. Kalmuss D et al. Op. Cit., p. ii. 38. Ingram DD et al. Op. cit. 39. Johnson K, Rosenbaum S. and Simons I. The Data Book. Washington, D.C.: Children's Defense Fund, 1985. 40. Hughes D, Johnson K, Rosenbaum S. and Simons J. Maternal and Child Health Data Book: The Health of America's Children. Washington, D.C.: Children's Defense Fund, 1986. 41. Hughes D, Johnson K, Rosenbaum S. Simons 3, and Butler E. The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1987. 42. Hughes D et al. The Health of America's Children: Maternal and Child Health Data Book. 1988. Op. cit. 43. National Center for Health Statistics. Prenatal care, United States, 1969-75. Op. cit. 44. Ingram DD et al. Op. cit., p. 420. 4S. Ibid., p. 421-422. 46. Ibid.,p.415. 47. lohnson K. The demographics of prenatal care utilization. Paper prepared for the Committee on Outreach for Prenatal Care. Institute of Medicine, Washington, D.C., 1988.