J Public Health Med. 1996 Sep;18(3):321-8.

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Role of prenatal care in preterm birth and low birthweight in Portugal.
Barros H, Tavares M, Rodrigues T. Department of Hygiene and Epidemiology, University of Porto Medical School, Portugal. BACKGROUND: It remains unclear if benefits of prenatal care can be attributed to the amount and content of care or to uncontrolled risk factors that might also affect its use. This study was designed to evaluate the independent association between prenatal care adequacy and adverse pregnancy outcomes, measured either as the occurrence of preterm birth or low birthweight. METHOD: We studied 3734 single liveborn infants. Information on mothers' use of prenatal care, and demographic, anthropometric, behavioural, clinical and obstetric characteristics were obtained through questionnaire. Prenatal care was classified as inadequate, intermediate or adequate based on Kessner's Adequacy of Prenatal Care Index. To estimate the association of adequacy of prenatal care and the defined outcomes, both crude and adjusted odds ratios (OR) and 95 per cent confidence intervals (95 per cent CI) were calculated by means of unconditional logistic regression. RESULTS: Adequate and intermediate (compared with inadequate) prenatal care was significantly associated with a lower risk of preterm (OR = 0.20, 95 per cent CI 0.12-0.32, and OR = 0.35, 95 per cent CI 0.23-0.54, respectively) or low birthweight (OR = 0.23, 95 per cent CI 0.15-0.35, and OR = 0.31, 95 per cent CI 0.20-0.46, respectively). After adjusting for maternal age, social class, marital status, complications of pregnancy and type of hospital, the risk of preterm delivery remained significantly lower for women receiving adequate (OR = 0.18, 95 per cent CI 0.110.28) or intermediate care (OR = 0.35, 95 per cent CI 0.23-0.54). Adjusted for maternal body mass index, marital status, cigarette smoking, pregnancy weight gain and complications, type of hospital, newborn sex and gestational age, a significant decreased risk of low birthweight remained for infants of women with adequate (OR = 0.39, 95 per cent CI 0.23-0.65) or intermediate care (OR = 0.47, 95 per cent CI 0.29-0.76). CONCLUSIONS: Our findings show that in a population with free access to prenatal care, the quantitative adequacy of prenatal care has an independent effect on pregnancy outcome, whether assessed through the occurrence of preterm births or low birthweight infants.
Do babies' outcomes diminish when moms are underserved prenatally? Grace Schwane Poertner, RN, MSW, PhD, Wellness Research, a not-for-profit corporation, 119 S. Main St, Suite 203, St. Charles, MO 63301-2863, 636-946-4555, gpoertne@yahoo.com Does inadequate prenatal care or Medicaid coverage relate to survival among infants born above very-lowbirthweight (Above-VLBW: 1500 grams or more)? This study analyzes individual risk of death among infants born Above-VLBW. The population studied represents 99% of a one-year birth cohort. Data (N=275,895) are randomly sampled from linked birth/infant death records for the US cohort born in 1984; these represent the 50 states & DC. Survivors roughly represent the current US population of 19-year olds. Independent variables are: infant race (3 dichotomous for African-American, Caucasian, all others); parental (maternal age/education, marriage); maternal residence at birth - by county (3 dichotomous for urban, suburban, rural) and by state (3 Medicaid averages, including percent of poor covered by Medicaid). A dichotomous variable defines prenatal care according to Kessner's Index; inadequate prenatal care was experienced by 7.6% of survivors and 14.6% of infants who died. Medicaid coverage varied from 17% to 104% of the state's poverty population. The dependent variable is dichotomous: death or survival to 1-year of age. Logistic regression analyzes infant death odds, given Medicaid and

prenatal care, while controlling for infant race and parental factors. Results: Above-VLBW infant death odds increase significantly (1) for all races with inadequate prenatal care; (2) for Caucasians, where Medicaid covers fewer of the poor. Implications: national research such as this needs to be repeated at least once a decade to guide prenatal care policymaking and to assess progress in improving infant health outcomes among all races. Financial support: AHCPR/AHRQ, NASW. Learning Objectives: • Define grossly inadequate prenatal care. • Identify the best and worst of Medicaid coverage by state for moms and babies. • Apply the research typology presented here to future studies about infant health outcomes. Keywords: Prenatal Care, Infant Health Presenting author's disclosure statement: I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session. 1: J Public Health Med. 1996 Sep;18(3):321-8. Related Articles, Links

Role of prenatal care in preterm birth and low birthweight in Portugal.
Barros H, Tavares M, Rodrigues T. Department of Hygiene and Epidemiology, University of Porto Medical School, Portugal. BACKGROUND: It remains unclear if benefits of prenatal care can be attributed to the amount and content of care or to uncontrolled risk factors that might also affect its use. This study was designed to evaluate the independent association between prenatal care adequacy and adverse pregnancy outcomes, measured either as the occurrence of preterm birth or low birthweight. METHOD: We studied 3734 single liveborn infants. Information on mothers' use of prenatal care, and demographic, anthropometric, behavioural, clinical and obstetric characteristics were obtained through questionnaire. Prenatal care was classified as inadequate, intermediate or adequate based on Kessner's Adequacy of Prenatal Care Index. To estimate the association of adequacy of prenatal care and the defined outcomes, both crude and adjusted odds ratios (OR) and 95 per cent confidence intervals (95 per cent CI) were calculated by means of unconditional logistic regression. RESULTS: Adequate and intermediate (compared with inadequate) prenatal care was significantly associated with a lower risk of preterm (OR = 0.20, 95 per cent CI 0.12-0.32, and OR = 0.35, 95 per cent CI 0.23-0.54, respectively) or low birthweight (OR = 0.23, 95 per cent CI 0.15-0.35, and OR = 0.31, 95 per cent CI 0.20-0.46, respectively). After adjusting for maternal age, social class, marital status, complications of pregnancy and type of hospital, the risk of preterm delivery remained significantly lower for women receiving adequate (OR = 0.18, 95 per cent CI 0.110.28) or intermediate care (OR = 0.35, 95 per cent CI 0.23-0.54). Adjusted for maternal body mass index, marital status, cigarette smoking, pregnancy weight gain and complications, type of hospital, newborn sex and gestational age, a significant decreased risk of low birthweight remained for infants of women with adequate (OR = 0.39, 95 per cent CI 0.23-0.65) or intermediate care (OR = 0.47, 95 per cent CI 0.29-0.76). CONCLUSIONS: Our findings show that in a population with free access to prenatal care, the quantitative adequacy of prenatal care has an independent effect on pregnancy outcome, whether assessed through the occurrence of preterm births or low birthweight infants.

: Soc Sci Med. 1987;24(11):927-44.

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Accessibility, quality of care and prenatal care use in the Philippines.
Wong EL, Popkin BM, Guilkey DK, Akin JS. The patterns and determinants of prenatal care are examined through the use of a randomly selected sample of 3000 rural and urban women who were studied prospectively during pregnancy and at three or four days postpartum. A large number of policy factors were found to influence the choice of most frequently used type of traditional, modern public or modern private prenatal care and the number of visits to each type of care, but few affected the first month of visit. The quality of care provided, accessibility to this care, and insurance available to the mother all had important effects on prenatal patterns. Large differences exist in the set of feasible policy options for improving prenatal care in urban and rural areas. PMID: 3616686 [PubMed - indexed for MEDLINE]
International Family Planning Perspectives Volume 29, Number 3, September 2003 DIGEST

Unintended Pregnancy Is Linked to Inadequate Prenatal Care, but Not to Unattended Delivery or Child Health
Pregnancy intention status has little or no effect on medical supervision at delivery, child vaccination or adequacy of growth, once the impact of socioeconomic and demographic characteristics is accounted for; intendedness does appear to independently affect the odds of obtaining adequate prenatal care, however. According to an analysis of Demographic and Health Survey data from five developing countries, only in Peru was unwantedness at conception consistently associated with deficits in all four health indicators.1 Such associations were less consistent in the other four countries studied, where birth order appears to exert a stronger effect than intention status on maternal and child health outcomes. The analysis is based on Demographic and Health Survey data from Bolivia (1998), Egypt (1995), Kenya (1998), Peru (1996) and the Philippines (1998). Women who had had a live birth in the previous five years (three years for Kenya) were asked whether, at the time they conceived, they had wanted to be pregnant, would have preferred to wait until later or did not want any more children; unintended conceptions ending in births are thus referred to as mistimed or unwanted births. The investigators used logistic regression to examine whether intendedness at conception influenced whether the woman received inadequate prenatal care (none before the sixth month of gestation) or gave birth outside of a medical institution or without professional supervision. They also investigated whether children whose conception was unintended suffered adverse health effects by assessing the odds of incomplete vaccination coverage (among children aged one or older) and inadequate growth (among all living children).

Descriptive Data
Unintended (unwanted plus mistimed) births were most common in Peru and least common in Egypt (58% and 29%, respectively, of all births). The proportion of all births that were unwanted ranged from 11% in Kenya to 37% in Peru, and the proportion that were mistimed varied from 10% in Egypt to 39% in Kenya. In every country, unwanted births became more frequent as birth order increased and mistimed births became less frequent as the interval between births lengthened.

In all five countries, both inadequate prenatal care and unsupervised deliveries were significantly more common for unwanted than for wanted births. Some 27-71% of women who had an unwanted birth had received inadequate prenatal care, compared with 21-65% of those with a wanted birth. In addition, 56-62% of unwanted births were unsupervised by a medical professional, compared with 40-55% of wanted births. In all countries except Bolivia, children who had been unwanted at conception were significantly more likely not to have been vaccinated by age one. In the four other countries, 21-52% of children who had been unwanted at conception lacked full vaccination coverage, compared with 18-36% of wanted children. In contrast, inadequate growth was related to unwanted conceptions only in Bolivia and Peru, where 34% of children unwanted at conception were stunted, compared with 22-24% of wanted children.

Multivariate Analyses
In the analysis examining factors affecting the odds of receiving inadequate prenatal care, maternal education had a large, monotonic effect: The odds were 5-16 times as high among the least educated women as among the most educated women. Moreover, in all countries except Peru, birth order had a large independent and positive effect (i.e., the odds of inadequate care were significantly elevated for fifth- or higher-order births), and in Bolivia, Egypt and Peru, the odds of inadequate prenatal care were significantly higher in rural areas than in large cities (1.4-5.4). In all countries except Kenya, women living in the poorest households had significantly higher odds of inadequate prenatal care than those in the richest households (1.7-3.4). Net of the effects of these variables, Peruvian and Philippino women whose pregnancy was unwanted had independently elevated odds of having received inadequate prenatal care (odds ratios, 1.4 and 1.2, respectively). Unwantedness had no significant effect on the odds of inadequate prenatal care in Bolivia or Kenya; however, it had a negative effect in Egypt (0.8). In addition, in Kenya, Peru and the Philippines, women with a mistimed birth had higher odds of inadequate prenatal care than those with a wanted birth (1.2-1.3). Like inadequate prenatal care, unsupervised delivery was associated with higher birth order, lower maternal education, lower household wealth and rural residence. Once the effects of these factors were accounted for, Peruvian women whose pregnancy was unwanted had elevated odds of delivering without professional supervision (1.2); however, the odds for Egyptian women with an unwanted pregnancy were reduced (0.8). The logistic regressions examining child health outcomes included additional controls for the age and sex of the child. The effects of specific socioeconomic characteristics on vaccination coverage and stunting varied widely by country. The effects of pregnancy intention status on vaccination were significant in Egypt, Kenya and Peru, however. For example, the adjusted odds of not having received the full set of vaccinations were significantly elevated among Kenyan and Peruvian children who had been unwanted at conception (1.6 and 1.2, respectively) and among Egyptian children whose conceptions had been mistimed (1.4). No independent association emerged between intendedness and vaccination coverage in Bolivia or the Philippines. Finally, the odds of stunting among children who were unwanted at conception were significantly elevated only in Peru (1.2). (No data were available on this outcome from the Philippines.) Because unwantedness showed significant interactions with all explanatory variables, the authors stratified the women within each country by both educational level and area of residence. The results were broadly similar to those for the sample as whole. The authors note that intendedness at conception is difficult to measure precisely. However, their findings of rising levels of unwantedness with birth order and of mistimed births with birth interval length "demonstrate that these concepts are understood by many women and ... merit serious analysis." According to the investigators, their key result is the lack of consistent associations between intendedness and three of the four outcomes studied (i.e., unsupervised delivery, incomplete vaccination and stunting). This inconsistency reflects the interrelatedness of intendedness and birth order, given that birth order appears to have an even "stronger and more pervasive influence" than intendedness. The authors speculate that higher-order children in large families are at a health disadvantage compared with their first- and second-order siblings, and that large benefits for maternal and child health will accrue with the transition to smaller families. In the case of Peru in particular, where unwantedness was consistently associated with all four adverse health outcomes, improved contraceptive use "should lead to improvements in obstetric and child care, and in child growth."--L. Remez

REFERENCE
1. Marston C and Cleland J, Do unintended pregnancies carried to term lead to adverse outcomes for mother and child? an assessment in five developing countries, Population Studies, 2003, 57(1):77-93. http://www.guttmacher.org/pubs/journals/2914603.html PRENATAL CARE VISIT ARMM had the lowest percentage of women with the recommended four or more prenatal care visits, while NCR had the highest. Percent of women with surviving children below five years old who had four (4) or more prenatal care visits by region, Philippines: 2002. (N=6.78M) REGION Percent w/ 4 or more visits PHILIPPINES 67.5 NCR 85.1 CAR 53.9 Ilocos Region 54.9 Cagayan Valley 61.6 Central Luzon 71.2 Southern Tagalog 66.4 Bicol Region 58.1 Western Visayas 72.2 Central Visayas 73.6 Eastern Visayas 57.4 Western Mindanao 72.2 Northern Mindanao 75.0 Southern Mindanao 64.2 Central Mindanao 60.6 ARMM 47.9 Caraga 71.0 http://www.remedios.com.ph/fhtml/philstat_rh_pcv.htm

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