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The Effects of Prenatal Care on the Growth and Development of the Infant

Carlie Angelo, Layne Black, Ashley Dibble, Jenna Gibson, Kat Keller and Maura Kennedy

Nursing Department, Youngstown State University

NURS 3749: Nursing Research

Professor Kim Ballone

April 8, 2020
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Abstract

The purpose of this research report is to look at the relationship between prenatal care and the

effects it can have on the growth and development of infants. Prenatal care can improve

pregnancy outcomes, reduce complications and ensure a healthy pregnancy. Research studies

have shown that prenatal care can improve the health of the infant and reduce the risk of

congenital defects and health problems. However, many pregnant women do not seek prenatal

care and the overall health of the infant can be compromised. Barriers to receiving prenatal care

were explored to understand why pregnant women are not seeking care. Some barriers include

socioeconomic factors, drug and alcohol use, and the mental status of the pregnant woman.
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The Effects of Prenatal Care on the Growth and Development of the Infant

Throughout time there have been advancements in prenatal care as well as research that

has shown the benefits and effects that prenatal care has on the outcome of a pregnancy. Many

multifactorial studies have been conducted to prove the benefits of prenatal care on infant health.

Due to socioeconomic factors, access to care is not always obtainable. Extenuating factors such

as substance abuse, mental health, education level, financial problems, and healthcare

accessibility play a role in the level of prenatal care that is obtained. This leads to the question:

what is the effect of prenatal care on the growth and development of infants in relation to

socioeconomic status?

Literature Review

Introduction

In order to address this topic of whether prenatal care effectively decreases the risk of

congenital defects and has positive outcomes toward the infant’s health, information was

acquired via OhioLINK databases, specifically CINHAL plus and MEDLINE:

Sources were reviewed for comprehensive data collection regarding ways that prenatal care

positively affects the health of infants while significantly decreasing the risk of congenital

deformities. In addition, socioeconomic factors and barriers to care were considered. Barriers

include substance abuse, financial hardships, and access to maternal health care.

Prenatal Care

Ensuring that women have prenatal care is the first step to the success of a healthy

pregnancy and a healthy baby. According to UCR Health, prenatal care is the healthcare you

receive while pregnant (“Prenatal Care Is,” 2018). Regular prenatal care throughout a woman’s

pregnancy helps to catch potential concerns early on and reduces the risk of pregnancy and birth
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complications. A schedule is put into place for a pregnant woman’s prenatal visits: once a month

for the first twenty-eight weeks, every two weeks for weeks twenty-eight through thirty-six, and

every week from week thirty-six until delivery. The schedule may vary depending on the

doctor’s office and if the pregnancy is considered high risk. The obstetrician wants women to

attend every single visit to benefit the health of the baby. It is advised to see a doctor prior to

even becoming pregnant to start prenatal care, but if the pregnancy was unexpected, care should

be started as soon as possible. UCR Health states, “babies of mothers who do not get prenatal

care are three times more likely to have a low birth weight and have birth complications”

(“Prenatal Care is,” 2018). Women can reduce the risk of pregnancy complications in several

ways. Women who are pregnant are advised to follow a safe diet full of vitamins, minerals,

fruits, and vegetables, perform regular exercise, and avoid exposing themselves to toxic

substances that can be potentially harmful to the baby. Also, it is recommended to quit smoking

and avoid alcohol consumption throughout pregnancy.

Benefits

Through research, studies found many different benefits to prenatal care. Some of these

benefits include a decreased risk for preterm birth, low birth weight, and NICU admissions. One

study analyzed the benefits of group prenatal care compared to individual care.

ITT analyses show that GPNC was significantly associated with decreased risk of

preterm birth (10.6% risk in individual care and 7.5% risk in GPNC); decreased risk of

low birth weight (10.7% risk in individual care and 7.0% risk in GPNC); and decreased

risk in NICU admissions (10.1% risk in individual care and 6.2% risk in GPNC)

(Crockett et al., 2019).

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Involving all the criteria of prenatal care including attending scheduled appointments, eating the

correct foods, and taking the prescribed dose of prenatal vitamins will provide benefits to the

birth of the baby.

Prenatal vitamins

Prenatal vitamins are an important aspect of prenatal care to ensure a healthy pregnancy.

The types of vitamins and minerals a pregnant woman should take during pregnancy including

folic acid, calcium, and iron. According to the Center for Disease Control, pregnant women are

prescribed 400 micrograms of folic acid daily. Folic acid has been proven to reduce the risk of

neural tube defects in a fetus (“Folic Acid Helps,” 2020). Birth defects happen very early on in

pregnancy, making it imperative to take folic acid, even if the woman is not pregnant yet, to

decrease the risk of potential defects. These vitamins are taken in conjunction with nutrients

from the foods in a healthy diet.

Another factor associated with prenatal care and the effect it has on the infant is nutrition.

A study exploring the association between maternal prenatal multivitamin use and early infant

growth examined the benefits of vitamin use in pregnant women by looking at the percent fat

mass of an infant. The study was looking to see if vitamin use was a factor in childhood obesity.

The study states, “offspring of non‐users had a monthly increase in percent fat mass of 3.45%,

while offspring at the top quartile of multivitamin users had a monthly increase in percent fat

mass of 3.06%” (Sauder et al., 2016). The study concluded the use of multivitamin use in

preconception periods, as well as prenatal periods, show a decreased rate of growth for percent

fat mass during the first five months after birth. The study supports that the types of nutrients the

fetus is exposed to in utero can affect offspring adiposity beyond birth.

Vitamin D and Fetus Health

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Vitamin D has also been found to have positive health benefits to the fetus when taken

during the prenatal period. The recommended dose for Vitamin D during pregnancy is at least

400 IU (international units) a day and can be found in almost all prenatal vitamins. Many studies

have been conducted to view the effect of Vitamin D on fetal growth and development along

with why it is crucial to the fetus during pregnancy.

An accumulating body of evidence suggests that vitamin D is also crucial for fetal

development because of its important role during cell proliferation, differentiation, and

maturation processes…Also, vitamin D is important for placental function, calcium

homeostasis, and bone mineralization, which are all important determinants for fetal

growth and development (Miliku et al., 2016. pg. 1514.)

The American Journal of Clinical Nutrition (2016) analyzed a study done consisting of 7098

mothers and their offspring. During this study, Vitamin D levels were analyzed continuously and

in quartiles. It was found that mothers who had low Vitamin D concentrations had an increased

risk for preterm delivery, low birth weight, and small size for gestational age at birth (Miliku et

al., 2016. pg. 1520.) Entering prenatal care can help reduce these risks because the obstetrician

will look at lab work and prescribe prenatal vitamins accordingly.

Congenital Defects

According to the Centers for Disease Control and Prevention (2020), one in every 133

babies is born with a congenital defect each year in the United States. “Birth defects are

structural changes present at birth that can affect almost any part or parts of the body (e.g., heart,

brain, foot). They may affect how the body looks, works, or both. Birth defects can vary from

mild to severe” (Data and Statistics on Birth Defects, 2020). Many birth defects can be found

before birth if mothers appropriately follow their scheduled visits to their obstetrician. Therefore,
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getting the correct prenatal care before and during pregnancy is crucial to the prevention and

early detection of congenital defects. One of the most important factors in preventing congenital

defects is planning ahead. One of the most imperative and recommended prenatal vitamins to

take is 400 mcg of folic acid every day. According to the Centers for Disease Control and

Prevention (2020), getting the correct amount of folic acid before conception can help to prevent

major birth defects of the developing brain and spine. Other ways to prevent congenital defects

include seeing a healthcare professional regularly, avoiding harmful substances (such as alcohol,

smoking, and drugs) during pregnancy, maintaining a healthy weight, and having an overall

healthy lifestyle.

Neural Tube Defects Related to Folic Acid Intake

One of the most common and more preventable congenital defects are neural tube

defects. “Neural tube defects are major birth defects of the brain and spine that occur early in

pregnancy as a result of improper closure of the embryonic neural tube, which can lead to death

or varying degrees of disability. The two most common NTDs are anencephaly and spina bifida”

(Updated Estimates of Neural Tube Defects Prevented by Mandatory Folic Acid Fortification-

United States, 2015). A recent study was done to look at the effects of the mandated fortification

of enriched cereal grain products with 140 ug of folic acid per 100g.

Results showed that immediately after the mandatory fortification, the prevalence of

NTD cases declined. Fortification was estimated to avert approximately 1,000 NTDs

annually. The number of births occurring annually without NTDs that would otherwise

have been affected is approximately 1,326 (95% confidence interval = 1,122- 1,531). The

reduction in NTD cases inversely mirrors the increase in serum and red blood cell folate

concentrations among women of childbearing age… (Williams et al., 2015).

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The intake of folic acid is a mandatory effective public health policy and helps to prevent many

congenital defects every year. Folic acid is a synthetic form of folate, a B vitamin, can be found

in foods such as dark green leafy vegetables, legumes, and oranges. Getting prenatal care, such

as taking folic acid, prenatal vitamins, or seeing a healthcare professional, is directly related to a

decreased number of babies being born with congenital defects.

Infant Mortality and Prenatal Care

It is imperative for women who have pre-existing conditions, such as diabetes, obesity, or

a history of preterm birthing, to get the correct prenatal care. Having these conditions does not

mean that they cannot have a baby. Although it does mean they are considered a high-risk

pregnancy and should see a healthcare provider more often to prevent infant mortality or

congenital deformities. It was found that “Pre- gestational diabetes increases the risk for

multifactorial birth defects including those of the neural tube which is increased four to eightfold

over the general population… lack of control of diabetes is a significant contributor to fetal

overgrowth and stillbirth in women with diabetes” (Infant Mortality Lessons Learned from a

Fetal and Infant Mortality Review Program, 2017). Therefore, women who have a pre-existing

condition, such as diabetes, should go to their doctor and discuss a prenatal plan and a healthy

lifestyle to live in order to conceive a healthy baby. It is also important for women who have had

a history of preterm births to see their doctor to prevent that from occurring in further

pregnancies. “Women with a prior idiopathic preterm birth should receive counseling on the

recurrence risk for preterm birth in subsequent deliveries… risk of preterm delivery in a

subsequent pregnancy is reduced with the weekly use of progesterone” (Brown et al., 2017).

Getting prenatal care and seeing a healthcare professional can help to prevent infant mortality

and complications related to preterm birth.

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Postpartum Infant

Receiving the best prenatal care has a strong impact on the development of the fetus.

Postpartum is the time following childbirth. If prenatal care is obtained adequately and early on,

then the infant will have a greater chance of developing appropriately. According to NICHD,

prenatal care decreases the risk of pregnancy complications, as well as decreases the risk of

complications after pregnancy. (“What is Prenatal Care,” 2017). Mothers who do not have any

prenatal care are five times more likely to have their baby die compared to babies born to

mothers who had early prenatal care. “The prenatal period has been conceptualized as a sensitive

period in which suboptimal fetal environments can increase the risk of low birth weight and

contribute to long term risks of obesity and cardiometabolic disorders.” (Luecken et al., 2015).

This is stating that without prenatal care, the infant is more likely to be developmentally delayed

later in life. Having prenatal care can increase the chances of a doctor catching something before

it is too late. Wellness visits and health screenings of a newborn is very beneficial to the infant.

According to NCBI, going to well checks before the actual birth of the child can help reduce

birth risk factors. (Liu et al., 2017). Receiving prenatal care can decrease the chance of the

infant having a developmental delay or other health problems.

Milestones and Measurements Postpartum

There are many developmental milestones that a healthy infant should reach. The infant

is most likely to achieve these milestones if the mother had a healthy pregnancy. According to

the CDC, an infant should be able to search and turn their head towards sounds at two months,

gain head control at four months, and acquire two-handed, voluntary hand grasp at five months

(CDC’s Developmental Milestones, 2019). All these milestones are developed correctly and on

time with the help of prenatal care. A premature infant, which can be a result of little or no
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prenatal care, can have delayed milestones. The Yale School of Public Health has researched that

having prenatal care reduces the risk of having a preterm birth. (“Prenatal Care,” 2018). Prenatal

care, especially group prenatal care has shown a thirty-seven percent decreased risk for

premature infancy.

Measurements of an infant are a very important factor after birth in evaluating growth

and development. A newborn’s head is about one-fourth of the length of their body. The head

circumference is about thirty-three to thirty-five centimeters, which is initially larger than the

chest circumference. A healthy infant’s weight is typically around six to eight pounds. In the first

twelve months after birth, an infant’s weight typically triples. The risk of obesity at birth, as well

as being overweight at three months is decreased if the mother received prenatal care. The height

of an infant is averaged at twenty inches and they grow usually one inch monthly for the first six

months. Their height should increase by fifty percent by twelve months. Prenatal care has shown

to be effective in the development of the infant. By entering prenatal care, the infant can grow

normally and reach the developmental milestones at the appropriate time.

Barriers to Prenatal Care

Prenatal care has proven to have many benefits, but hardships are not uncommon

amongst pregnant women leading to them not receiving prenatal care. This can put the mother's

and infant’s well-being at risk. Some pregnant women do not receive any or inadequate prenatal

care due to a variety of socioeconomic barriers that they face. These barriers include financial

hardships, inadequate health insurance, inadequate transportation services, and a lack of

education.

Financial Uncertainties
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One socioeconomic factor that interferes with pregnant women receiving prenatal care is

financial barriers. According to the Institute of Medicine Committee (1988), pregnancy and

childbirth are a great financial burden, therefore “financial status, and health insurance coverage

in particular, plays a major role in determining whether or not prenatal care is secured” (p.55).

When a woman is experiencing financial hardships, she is less likely to seek out prenatal care

due to the uncertainty of how she will be able to afford the doctors’ appointments, essential

prenatal vitamins, maternal tests, and fetal monitoring tests. A respondent in the Structural and

Socio-cultural Barriers to Prenatal Care in a US Marshallese Community study stated, “if we go

to see the doctors, and we don’t have insurance, they will tell us to pay, but we don’t have the

money to [pay]" (Ayers et al., 2018). In a study, 56% of pregnant women reported some form of

material hardship (Katz at el., 2018). Material hardships include not having enough food in the

house, a lack of clothing and transportation or simply not having enough money to make

payments on bills. These women canPa experience nutritional shortfalls and unhealthy living

conditions putting the mom and baby at an increased risk for complications. In these cases,

prenatal care is less desired because of the stress from the financial hardships they are already

experiencing. Whether a woman is unemployed, has a low annual income, on Medicaid or

uninsured, when she does not have the access to receive this prenatal care it can overall

negatively affect the fetus and infant.

Insurance Eligibility

Pregnant women face insurance barriers when trying to secure prenatal care. Maternal

care can be an extra charge for some insurances. This results in pregnant women delaying

prenatal care until it is time to give birth because they do not have the means to pay from the lack

of insurance coverage they have (Ayers et al., 2018). Having inadequate or no maternity care
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insurance can result in a longer wait period for an appointment. It is so important to establish

care early on in pregnancy because first-semester prenatal care can “improve pregnancy

outcomes, provide better gestational age dating, identify and modify risk factors, prevent

complications, and allow for healthier pregnancies” (Shah et al., 2018). Having to wait for an

appointment because insurance may or may not provide coverage, delays medical staff from

providing important prenatal education. Additionally, the insurance eligibility processes can be

very complicated leaving women feeling confused, overwhelmed, and frustrated. Participants in

a study expressed they did not know where to go or how to apply for pregnant women’s

Medicaid (Ayers et al., 2018). This shows some people have an overall lack of an understanding

of insurance leaving pregnant women without prenatal care. According to the study, Improving

Rates of Early Entry Prenatal Care in an Underserved Population, simplifying the process for

insurance approval and educating patients about the healthcare system has increased the number

of women to enter prenatal care (Shah et al., 2018).

Transportation

Another socioeconomic barrier that women face in receiving prenatal care is inadequate

transportation services. Many studies identified that one of the most common unmet needs for

why women do not receive prenatal care involved transportation (Katz et al., 2018). In the study,

Material Hardship and Mental Health Symptoms Among a Predominantly Low-Income Sample

of Pregnant Women Seeking Prenatal Care, 37.3% of women experience hardships involved with

transportation to medical appointments (Katz at el., 2018). Transportation problems that are

linked to insufficient use of prenatal care are “long distances to reach a provider, the high cost of

transportation, and no transportation whatever” (Institute of Medicine (US) Committee to Study

Outreach for Prenatal Care, 1988, p.73). Transportation barriers can be a consequence of
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financial hardships because women may not be able to afford a car or even gas to get to and from

an appointment. Lacking in self-transportation puts dependence on the public transportation

system which may or may not be offered for prenatal services, especially in rural areas and for

morning appointments when the buses aren’t running yet. Another problem pregnant women

may face is the question of whether going to prenatal care appointments are worth the drive

especially if they live in rural areas. According to Ayers et al. a participant in her study stated, “if

there is a ride, I will go to prenatal care” (Ayers et al., 2019). This shows that transportation is a

barrier deterring women from receiving essential prenatal care.

Education Level

A low level of education can put women at risk for insufficient prenatal care. This

disadvantage can cause poor reproductive health knowledge. Pregnant women may not think

they need prenatal care, they may not know the benefits, or they may not know what it is or how

to receive it. A low level of education can ultimately lead to low income. With a lower income, a

pregnant woman may see prenatal care as an added cost and not a necessary expense. This

cascade of events can be detrimental to the health of the mother and fetus. Additionally, pregnant

women may experience an uncertainty about where to go to receive prenatal care. This is the

result of a lack of information being relayed to the public about locations that give prenatal care

and its benefits (Ayers et al., 2018). Ultimately improving community outreach and emphasizing

the importance of prenatal care can increase the number of less-educated women who enter

prenatal care (Shah et al., 2018).

Mental Health

Mental health has become a prevalent topic in American society. A study found that

mental illness occurs in between 10 and 13 percent of pregnant women (McDonald et al., 2020).
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This study focused on the effect of one or more psychosocial factors including mental illness,

substance abuse and interpersonal traumas on 1,656 pregnant women (McDonald et al., 2020).

Each of these factors has been associated with poor maternal and infant health outcomes on their

own. Roughly 35% of these women reported they had some kind of mental illness. According to

the MGH Center for Women’s Mental Health, “women who suffer from a psychiatric illness

during pregnancy are less likely to receive adequate prenatal care and are more likely to use

alcohol, tobacco, and other substances known to adversely affect pregnancy outcomes”

(Massachusetts General Hospital, 2018). Mental health itself does not have a direct effect on the

health of the fetus or development of the infant. However, mental illness prevents some pregnant

women from receiving perinatal care and increases their likelihood to participate in illicit

activities. These actions result in the inhibition of proper growth and poor perinatal outcomes.

Substance Abuse

Substance abuse refers to the use of drugs and or alcohol. One study found that roughly

5.4% of pregnant women reported their current use of illicit drugs, roughly 10% reported alcohol

use and 3.4% reported a pattern of binge drinking. This same study found that opioid use in

pregnant women increased six-fold over the past decade (Tan et al., 2015). Due to the stigma

against drug or alcohol dependence, some pregnant women do not seek treatment for their

dependence during their pregnancy which results in issues postpartum for the infant. If opioids

are stopped abruptly, it can cause issues not only to the woman but also increase poor perinatal

outcomes (Shrestha et al., 2018). If pregnant women do seek care for drug addiction, there is the

possibility of medication-assisted treatment (MAT). This is when somebody addicted to opioids

transitions to medications like methadone or buprenorphine that curb cravings for the drug itself

and can eventually help to wean the person off of the drug completely. It is shown that MAT
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results in “social stabilization, increased utilization of prenatal care, minimization of the blood-

born pathogen transmission associated with injectable drug use” (Shrestha et al., 2018).

In this study, the groups were broken down into those using MAT, alcohol (ALC), MAT

+ ALC, and the control group. It was shown that MAT and MAT + ALC users were “more likely

to be single/separated or divorced, to have lower education levels, at least one medical condition,

and an unplanned pregnancy compared to controls” (Shrestha et al., 2018). This statement shows

a link between socioeconomic status and the use of drugs and or alcohol during pregnancy.

Substance abuse is associated with increased consumption of calories with an inadequate

intake of nutrient-dense foods. If nutrient-dense foods are not consumed there is an insufficient

intake of folic acid, choline, vitamin B6, and vitamin B12. These are commonly taken as both

pre and perinatal supplements. Micronutrients like vitamin B6 and choline are known as

neuroprotectors that help to prevent damage related to a fetus that has been exposed to alcohol.

This study showed that only 11.5% of MAT participants took multivitamins before conception

and had inadequate intake of nutrients in their diet during pregnancy (Shrestha et al., 2018). So,

in this case, pregnant women not only did not take prenatal vitamins, but they also did not

consume adequate amounts of the nutrients during pregnancy. Due to this documented lack of

adequate nutrition, there is a need for dietary interventions in the populations that use substances

during pregnancy. For these women who suffer from substance abuse, nutrition guidance can be

provided at prenatal appointments.

Conclusion

Studies show that establishing early prenatal care and continuation until the time of

delivery is one of the most effective interventions in reducing congenital deformities and health

complications in the infant. Results indicate that prenatal vitamins and nutrition have a positive
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impact on fetal development. Receiving prenatal care will ensure the fetus is on track for

reaching developmental milestones. Socioeconomic barriers such as, low income, a low level of

education and access to care certainly influence the number of pregnant women who enter

prenatal care. Suffering from mental health problems and substance abuse are internal barriers

some pregnant women face that influence whether they receive care. Not entering care due to

these barriers can negatively affect both the mother and infant.
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