Adequacy Of Prenatal Care Utilization Research Articles

The association of Chinese and American antenatal care utilization indices with birth outcomes.

Few comparisons have been implemented between different prenatal care utilization indices and their effects on adverse outcomes. This study investigated the appropriateness of Chinese antenatal care (ANC) regulations and compared Chinese and American adequacy of prenatal care utilization (APNCU) scores. From 2010 to 2022, the medical records of 60,114 pregnant women were collected from the electronic medical record system (EMRS) in Zhoushan, China. ANC utilization was measured using the APNCU score and five times antenatal care (ANC5). Birth weight outcomes, including small for gestational age (SGA) and large for gestational age (LGA), low birth weight (LBW), macrosomia, birth weight, and preterm birth (PTB), were utilized as outcomes. Multinomial, linear, and logistic regression were used to analyze the association of ANC5 and APNCU with outcomes, respectively. Crossover analysis was implemented to compare the interaction between ANC5 and APNCU on the outcomes. Women who received inadequate prenatal care had increased odds for PTB (ANC5: odds ratio (OR) = 1.12, 95% confidence interval (95%CI) = 1.03-1.21; APNCU: OR = 1.18, 95%CI: 1.07-1.29), delivering SGA infants (ANC5: OR = 1.13, 95%CI = 1.07-1.21; APNCU: OR = 1.11, 95%CI = 1.03-1.20). Crossover analysis revealed that inadequate prenatal care in APNCU only was significantly associated with an increased risk of PTB (OR = 1.48, 95%CI: 1.26-1.73). Women with inadequate prenatal care in ANC5 or APNCU were more likely to suffer from adverse birth outcomes, including PTB, birth weight loss, SGA, and LBW. It indicated that adequate prenatal care is necessary for pregnant women. However, there were interactions between ANC5 and APNCU on PTB, with inadequate prenatal care use by APNCU showing the highest risk of PTB. This indicates that APNCU would be a better tool for evaluating prenatal care use.

How Much is too Much? High Utilization of Prenatal Care and Its Impact on Primary Cesarean Birth Among Women in the United States.

Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth. The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method. Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18-1.28). Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births.

Adequacy of Prenatal Care Utilization in a Pathways Community HUB Model Program: Results of a Propensity Score Matching Analysis.

The THRIVE (Toward Health Resiliency and Infant Vitality & Equity) program aims to reduce racial disparities in birth outcomes by addressing individual risks and social determinants of health using the Pathways Community HUB model. This study examines (1) racial disparities among THRIVE participants and propensity score matched (PSM) comparisons in adequacy of prenatal care, and whether THRIVE participation (2) attenuates such disparities, and (3) improves odds of having adequate prenatal care. Birth certificate and Care Coordination Systems client data were merged for analysis. PSM was employed for 1:1 matching per birth year (2017-2020) and race for participating and non-participating first-time births in Stark County, Ohio. Additional matching variables were age, marital status, education attainment, birth quarter, census tract poverty rate, and Women Infant & Children (WIC) enrollment. Logistic regression assessed racial differences in adequate prenatal care utilization (APNCU) and examined differences between the intervention and comparison groups on APNCU. THRIVE participants averaged more prenatal care visits and had a higher percentage of adequate care utilization than the comparison group. THRIVE program participation, educational attainment, and WIC enrollment were associated with higher odds of adequate prenatal care utilization (OR 4.74; 95% CI 2.62, 8.57). Race was not significant for APNCU. Although accessing and maintaining prenatal care is only one aspect of improving birth outcomes, the findings contribute to the understanding of the effects of the program of interest and other similar programs on factors which may promote desired birth outcomes in high-risk populations.

Host‐country language proficiency and migrant‐native disparities in prenatal care utilization: A nationwide study in Portugal

AbstractBackgroundMigrant‐native disparities in perinatal health and care utilization are well‐established, yet most evidence comes from countries without universal health coverage. Migrant‐specific factors potentially contributing to such disparities are seldom examined. We investigated the association between migration and host‐country language proficiency and inadequate utilization of prenatal care (PNC) in Portugal.MethodsWe used robust Poisson regression to analyze data from 1419 migrant and 2477 native women enrolled in the Portuguese Bambino cohort study who had given birth at a Portuguese public hospital between 2017 and 2019. Migrant women's language proficiency was self‐rated for understanding, speaking, reading, and writing skills. PNC utilization inadequacy was assessed using three dimensions: initiation, number of visits, and the modified Adequacy of Prenatal Care Utilization (mAPNCU) Index score.ResultsMigrant women were overall more likely to initiate PNC late and have inadequate/intermediate mAPNCU scores than natives. Migrant‐native disparities in the number of PNC visits were only observed among recent migrants (≤5 years in Portugal). Full, intermediate, and limited Portuguese skills were associated with increasingly higher risks of late PNC initiation (aRR 1.34 [95%CI 1.20‐1.50]); (aRR 1.52 [95%CI 1.28‐1.80]); (aRR 1.91 [95%CI 1.52‐2.40]), inadequate number of PNC visits (aRR 1.06 [95%CI 0.93‐1.22]); (aRR 1.14 [95%CI 0.97‐1.34]); (aRR 1.57 [95%CI 1.19‐2.07]), and inadequate/intermediate mAPNCU scores (aRR 1.18 [95%CI 1.07‐1.32]); (aRR 1.30 [95%CI 1.11‐1.53]); (aRR 1.69 [95%CI 1.38‐2.07]) compared with native Portuguese skills, respectively.ConclusionsMigrant‐native disparities in PNC utilization are present in Portugal, despite universal health coverage. Recent migrants and women with limited language competence are the most vulnerable to inadequate PNC use.

Posttraumatic stress and prenatal care adequacy among Black/African American women

Black/African American women with trauma histories experience a disproportionate burden of adverse perinatal outcomes. One mechanism for this association is inadequate prenatal care, as avoidant symptoms are a hallmark of posttraumatic stress disorder (PTSD). The objective of this study is to examine the association between PTSD symptoms and adequacy of prenatal care among Black/African American women. This retrospective cohort study included all pregnant women who self-identified as Black/African American and were referred to a hospital’s integrated mental health program between 2017-2021. All participants completed a PTSD Checklist -Civilian Version (PCL-C) as a part of an initial mental health evaluation. The EHR was reviewed to codify adequacy of prenatal care, which was assessed in three ways: late initiation of prenatal care (defined as gestational age at the first prenatal visit > 12 weeks), the ratio of no-show to attended prenatal visits, and the Adequacy of Prenatal Care Utilization (APNCU) Index. Bivariable analyses were performed. A propensity score for a positive PTSD screen was generated using confounders generated from a directed acyclic graph. This propensity score was included in multivariable models to control for imbalance across the exposure. Of the 111 women who met inclusion criteria, 57 (51%) screened positive on the PCL-C. Sample characteristics, stratified by a positive screen, are shown in Table 1. PCL-C score was associated with late initiation of prenatal care, the ratio of no-show to attended prenatal visits, and non-adequate prenatal care defined by the APNCU index (Table 2). The associations between late initiation of care and non-adequate APNCU index persisted in multivariable analyses. In this sample of pregnant Black/African American women with an identified mental health condition, PTSD symptoms were associated with inadequate prenatal care. The high prevalence of PTSD symptoms and the association with prenatal care emphasizes the importance of future research focused on trauma-related interventions for Black/African-American women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Excess Preterm Birth Rate Among US-Born (Compared to Foreign-Born) Black Women: The Role of Father's Education.

To ascertain the component of the excess preterm birth (< 37weeks, PTB) rate among US-born (compared to foreign-born) Black women attributable to differences in acknowledged father's education attainment. Stratified analyses and Oaxaca-Blinder decomposition methods were performed on the 2013 National Center for Health Statistics birth certificate files of singleton infants with acknowledged fathers. US-born Black women (N = 196,472) had a PTB rate of 13.3%, compared to 10.8% for foreign-born Black women (N = 51,334; Risk Difference (95% confidence interval) = 2.5 (2.3, 2.8). Infants of US-born black women had a greater a percentage of fathers with a high school diploma or less and a lower percentage of fathers with bachelor's degrees or higher than their counterparts of foreign-born women. In both subgroups, PTB rates tended to decline as the level of paternal education attainment rose. In an Oaxaca model (controlling for maternal age, education, marital status, parity, adequacy of prenatal care utilization, and chronic medical conditions), differences in paternal education attainment explained 15% of the maternal nativity disparity in PTB rates. In contrast, maternal education attainment accounted for approximately 4% of the disparity in PTB rates. Acknowledged father's low level of education attainment, or something closely related to it, explains a notable proportion of the disparity in PTB rates between US-born and foreign-born Black women.

The impact of antenatal care utilization on admissions to neonatal intensive care units and perinatal mortality in Georgia.

IntroductionAppropriate antenatal care (ANC) utilization has direct, significant effects on perinatal mortality (PM). Georgia has one of the highest PM rates (11.7 per 1000 births) in Europe and launched a more intensive ANC programme in 2018.AimTo evaluate the associations between the Adequacy of Prenatal Care Utilization (APNCU) index and neonatal intensive care unit (NICU) admission and PM in Georgia.MethodsThe Georgian Birth Registry (GBR), with linkage to the Vital Registration System, was used as the main data source; 148,407 eligible mothers and singleton newborns were identified during the observation period (2017–2019). The main exposure was ANC utilization, measured by the APNCU index, and the hospitalization registry was used to validate NICU admissions. Logistic regression analysis was used to assess the associations between the exposure and outcomes while controlling for potential confounders.ResultsThe overall PM rate was 11.6/1000 births, and the proportion of newborns with a NICU admission was 7.8%. 85% of women initiated ANC before gestational age week 12. According to the APNCU index, 16% of women received inadequate, 10% intermediate, 38% adequate, and 36% intensive care. Women who received intermediate care had the lowest odds of PM (adjusted odds ratio [AOR] = 0.56, 95% confidence interval [CI] 0.45–0.70), and newborns of women who received inadequate care had the highest odds of NICU admission (AOR = 1.16, 95% CI 1.09–1.23) and PM (AOR = 1.18, 95% CI 1.02–1.36).ConclusionANC utilization is significantly associated with newborn asmissions to NICU and PM in Georgia. Women received inadequate care experienced the highest odds of newborn admissions to NICU and PM.

Systematic review of the measurement properties of indices of prenatal care utilization

BackgroundAn accurate assessment of the adequacy of prenatal care utilization is critical to inform the relationship between prenatal care and pregnancy outcomes. This systematic review critically appraises the evidence on measurement properties of prenatal care utilization indices and provides recommendations about which index is the most useful for this purpose.MethodsMEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched from database inception to October 2018 using keywords related to indices of prenatal care utilization. No language restrictions were imposed. Studies were included if they evaluated the reliability, validity, or responsiveness of at least one index of adequacy of prenatal care utilization. We used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. We conducted an evidence synthesis using predefined criteria to appraise the measurement properties of the indices.ResultsFrom 2664 studies initially screened, 13 unique studies evaluated the measurement properties of at least one index of prenatal care utilization. Most of the indices of adequacy of prenatal care currently used in research and clinical practice have been evaluated for at least some form of reliability and/or validity. Evidence about the responsiveness to change of these indices is absent from these evaluations. The Adequacy Perinatal Care Utilization Index (APNCUI) and the Kessner Index are supported by moderate evidence regarding their reliability, predictive and concurrent validity.ConclusionThe scientific literature has not comprehensively reported the measurement properties of commonly used indices of prenatal care utilization, and there is insufficient research to inform the choice of the best index. Lack of strong evidence about which index is the best to measure prenatal care utilization has important implications for tracking health care utilization and for formulating prenatal care recommendations.

Influence of the Adequacy of the Prenatal Care Utilization Index on Small-For-Gestational-Age Infants and Preterm Births in the United States.

Little is known about the associations of Adequacy of Prenatal Care Utilization (APNCU) index with small-for-gestational-age (SGA) infants and preterm births. This study investigated the association between the Adequacy of Prenatal Care Utilization (APNCU) index in relation to small-for-gestational-age (SGA) infants and preterm births. We used data from 212,050 pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) between 2004 and 2011. Multivariable logistic regression analyses were performed to examine the effect of the APNCU index on SGA infants and preterm births after controlling for maternal sociodemographic factors. Women who received adequate-plus prenatal care in reference to adequate prenatal care had increased odds for delivering SGA infants (adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03–1.15). Women with 9–11 prenatal care visits had increased odds of delivering SGA infants (AOR = 1.07, 95% CI = 1.02–1.14) compared to those with more than 12 visits. Among the four APNCU index categories, the highest rate of preterm births was observed in the adequate-plus group. Compared to those with adequate prenatal care, women who received adequate-plus prenatal care had increased odds of preterm birth (AOR = 1.69, 95% CI = 1.55–1.84). Compared to those with more than 12 visits, women with fewer than eight prenatal care visits had increased odds of preterm birth (AOR = 1.29, 95% CI = 1.13–1.48). In conclusion, women in the adequate-plus APNCU index category were more likely to deliver SGA infants and to have preterm births compared to those in the adequate APNCU index category. Women in the U.S. with high-risk pregnancies were prone to receiving adequate-plus prenatal care. Future prospective studies are warranted to investigate the influence of APNCU index in relation to pregnancy and birth outcomes.

Prenatal care of women who give birth to Children with Fetal Alcohol Spectrum Disorder in a universal health care system: A retrospective cohort study utilizing linkable administrative data

IntroductionFetal Alcohol Spectrum Disorder (FASD) is a significant public health concern. Prenatal care (PNC) settings are integral to preventing prenatal alcohol exposure as physicians delivering PNC services are in a unique position to reduce alcohol consumption during pregnancy. However, few studies have investigated PNC use among women who drink during&#x0D; Objectives and ApproachAnalysis was conducted of women with children born in Manitoba between April 1, 1984 and Mach 31, 2012, with follow up till 2013 using linkable administrative and novel clinic data. Study group included women whose child(ren) were diagnosed with FASD from 1999 to 2012 (n=702) at a centralised FASD diagnostic clinic. Comparison group included women from the general population whose children who did not have an FASD diagnosis (n=2097), matched on the index child’s birthdate, postal code, and SES. Adequacy of PNC utilization was defined using the revised Graduated Index of Prenatal Care Utilization.&#x0D; ResultsThis is the first population-based study to investigate rates of PNC usage of women who have given birth to children with FASD. Rates of inadequate PNC were higher among the study group (adjusted RR 2.47, 95% CI 2.08 to 2.94), as well as no PNC (adjusted RR 3.55, CI 2.42 to 5.22). Among the study group 63% accessed PNC, with 59% receiving intermediate, adequate, or intensive PNC.&#x0D; Conclusion/ImplicationsResults represent opportunity for screening and brief intervention programs to be delivered in PNC health care settings, as well as outreach programs to facilitate the uptake of PNC among high risk women.

Policing as a Social Determinant of Health: The Impact of Drug Enforcement on Prenatal Care Utilization in Urban Communities.

Background: Prenatal care is an important health behavior for optimizing maternal-child outcomes. Social ecological studies have identified both individual- and community-level factors that significantly impact this health behavior. While public health researchers have demonstrated that police officers can act as both barriers and facilitators to health promoting behaviors, little is known about their effect on women’s adequacy of prenatal care utilization (APNCU). Aim of the Study: Use a mixed-model procedure that nests individuals within their census-tracts of residence to examine the effects of drug arrests (a common police strategy in vulnerable communities) on APNCU among pregnant women residing in an urban setting. Results: While controlling for several known individual-level factors (i.e., maternal age, education, and pregnancy risk/complications), the study found that police drug arrests negatively impacted APNCU, as did structural disadvantage, distance to primary care, and residential stability. As expected all three individual-level factors positively impacted APNCU. Conclusions: This research demonstrates that the police are an important social determinant of prenatal care and further supports the limited research on the effect of American policing tactics on community health promotion/disease prevention efforts. We hope this research initiates a new policy paradigm that views the police as an institution of public health as much as an institution of criminal justice.

State Medicaid Expansions for Parents Led to Increased Coverage and Prenatal Care Utilization among Pregnant Mothers.

To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant. Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System. The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents. I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion. I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization. Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy.

Does Better Spatial Access Lead to Better Use of Prenatal Care? A Population Study in Georgia

Understanding the effect of spatial accessibility on service utilization is essential to facilitate prenatal care delivery. Previous studies suggest that mothers with better spatial access are more likely to receive adequate prenatal care. Their conclusions, however, are limited by use of small samples and inappropriate spatial accessibility measurements. This article examines the role of spatial accessibility in explaining the variation of prenatal care utilization among 202,377 mothers in Georgia from 2009 to 2011. Specifically, we use geographic information systems and spatial analysis methods to explore the spatial pattern of inadequate prenatal care utilization. A two-transportation-mode, two-step floating catchment area method is used to measure the spatial access to prenatal care by census tract. The effects of spatial accessibility, combined with the influences of demographic, socioeconomic, behavioral, and medical factors, on the adequacy of prenatal care utilization are investigated with statistical models at the individual level. The results show that mothers with better spatial access are less likely to have adequate prenatal care. The inconsistency of this finding with other existing evidence suggests that the effects of spatial accessibility on health service utilization could be complicated and context specific.

Measuring adequacy of prenatal care: does missing visit information matter?

Kotelchuck's Adequacy of Prenatal Care Utilization (APNCU) Index is frequently used to classify levels of prenatal care. In the Finger Lakes Region (FLR) of upstate New York, prenatal care visit information late in pregnancy is often not documented on the birth certificate. We studied the extent of this missing information and its impact on the validity of regional APNCU scores. We calculated the "weeks between" a mother's last prenatal care visit and her infant's date of birth. We adjusted the APNCU algorithm creating the Last Visit Adequacy of Prenatal Care (LV-APNC) Index using the last recorded prenatal care visit date as the end point of care and the expected number of visits at that time. We compared maternal characteristics by care level with each index, examining rates of reclassification and number of "weeks between" by birth hospital. Stuart-Maxwell, McNemar, chi-square, and t-tests were used to determine statistical significance. Based on 58,462 births, the mean "weeks between" was 2.8weeks. Compared with their APNCU Index score, 42.4 percent of mothers were reclassified using the LV-APNC Index. Major movement occurred from Intermediate (APNCU) to Adequate or Adequate Plus (LV-APNC) leaving the Intermediate Care group a more at-risk group of mothers. Those with Adequate or Adequate Plus Care (LV-APNC) increased by 31.6 percent, surpassing the Healthy People 2020 objective. In the FLR, missing visit information at the end of pregnancy results in an underestimation of mothers' prenatal care. Future research is needed to determine the extent of this missing visit information on the national level.

Maternal determinants of pregnancy complications, birth outcomes, and postpartum depression (369.8)

Various socio‐demographic and lifestyle factors have independently been reported to be associated with pregnancy complications, birth outcomes. We aimed to identify if prepregnancy BMI, gestational weight gain (GWG) and Adequacy of Prenatal Care Utilization (APNCU) are collective determinants of pregnancy complications, birth outcomes and postpartum depression. Multiple logistic regression analyses were conducted using the data of 7,911 Michigan’s 2007‐2010 Pregnancy Risk Assessment Monitoring System (PRAMS). After age, race/ethnicity, education, incomes, smoking status, and gestational weeks were controlled, prepregnancy BMI&gt;30 was associated with high risk for large‐for gestational age (LGA) (aOR:1.97, 95% CI:1.61‐2.42), gestational hypertension (GH) (2.68, 2.23‐3.22), and gestational diabetes mellitus (GDM) (4.33, 2.79‐6.71) and low risk for small‐for‐gestational age (SGA) (0.70, 0.55‐0.87); excessive GWG increased the risk for LGA (1.73, 1.40‐2.12), macrosomia (3.23, 1.70‐6.13), and GH (1.36, 1.12‐1.64) and decreased the risk for SGA (0.56, 0.45‐0.68) and preterm labor (0.75, 0.64‐0.88). Compared to the women who started prenatal care in the first trimester, those who received no prenatal care had a higher risk for LGA (3.06, 1.05‐8.91). Prenatal care received during the 2nd or 3rd trimesters decreased the risk of having postpartum depression (0.73, 0.56‐0.95). However, APNCU was not associated with pregnancy complications, birth outcomes and postpartum depression. Maintaining healthy prepregnancy BMI and adequate GWG are important determinants for optimal health outcomes of pregnant women.

Insurance Coverage and Prenatal Care Among Low-Income Pregnant Women

The "Unborn Child" (UC) option provides state Medicaid/Children's Health Insurance Program (CHIP) programs with a new strategy to extend prenatal coverage to low-income women who would otherwise have difficulty enrolling in or would be ineligible for Medicaid. To examine the association of the UC option with the probability of enrollment in Medicaid/CHIP during pregnancy and probability of receiving adequate prenatal care. We use pooled cross-sectional data from the Pregnancy Risk Assessment Monitoring System from 32 states between 2004 and 2010 (n = 81,983). Multivariable regression is employed to examine the association of the UC option with Medicaid/CHIP enrollment during pregnancy among eligible women who were uninsured preconception (n = 45,082) and those who had insurance (but not Medicaid) preconception (n = 36,901). Multivariable regression is also employed to assess the association between the UC option and receipt of adequate prenatal care, measured by the Adequacy of Prenatal Care Utilization Index. Residing in a state with the UC option is associated with a greater probability of Medicaid enrollment during pregnancy relative to residing in a state without the policy both among women uninsured preconception (88% vs. 77%, P < 0.01) and among women insured (but not in Medicaid) preconception (40% vs. 31%, P < 0.01). Residing in a state with the UC option is not significantly associated with receiving adequate prenatal care, among both women with and without insurance preconception. The UC option provides states a key way to expand or simplify prenatal insurance coverage, but further policy efforts are needed to ensure that coverage improves access to high-quality prenatal care.

Total Trihalomethanes in Public Drinking Water Supply and Birth Outcomes: A Cross-Sectional Study

Reproductive effects of long-term, low-dose exposure to disinfectant by-products have not been consistently documented in large populations despite the known toxicity of high exposures and the wide-spread occurrence of low concentrations in public drinking water. We investigated the effect of low-dose exposure to total trihalomethanes (TTHM) on birth weight and gestational term in New York State. All singleton live births from 1998 through 2003 in 62 counties in New York State were linked with public water supply (PWS) system boundaries based on mother's residential address on birth certificate. Using the data from public water supply system, TTHM measurements were assigned geographically and temporally to each birth record linked with PWS boundary. Individual level maternal information including mother's race, ethnicity, education, employment status, smoking, age, along with adequacy of prenatal care utilization and infant's gender was used in a logistic model to adjust for potential confounding. A small non-linear association was detected between TTHM exposure and low birth weight (<2,500 g) births (OR 1.14; 95 % confidence interval (CI) 1.08-1.21), preterm births (OR 1.14; 95 % CI 1.08-1.20) and for small for gestational age births (OR 1.10; 95 % CI 1.04-1.16) suggesting a small increase in risk for these birth outcomes with chronic low maternal exposure to drinking water containing trihalomethanes. Maternal exposure to TTHMs during pregnancy may be associated with low birth weight, preterm births and small for gestational age births.

Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal

To develop and apply a new instrument to evaluate prenatal care based on the guidelines of the Brazilian Humanization Program for Prenatal Care and Birth, including quantitative and qualitative elements distributed according to the evaluation triad of structure, process, and outcomes. An analytic, descriptive, quantitative cross-sectional study was carried out with 238 women receiving care in 44 primary care services in the city of João Pessoa, Northeast Brazil, between November 2010 and December 2011. Physicians and nurses involved in prenatal care were also interviewed. The instrument developed by the investigators contains 23 questions relating to structure, process and outcomes of pre-natal care. Based on the information collected, pre-natal care was classified according to an IPR/Pre-Natal index (Índice IPR/Pré-Natal, where I stands for infrastructure, P for work process and R for results). A value of 1 is attributed to each question if it complies with the criteria established for quality, or 2 if it does not comply. The percent of adequate answers in relation to the 23 total questions is used to classify prenatal care as: upper adequate (100% adequate answers); adequate (>75%); intermediate (51 to 74%); and inadequate (<50%). The classification categories for the Pre-Natal/IPR index were compared to those of the Kessner and Adequacy of Prenatal Care Utilization (APNCU) indices. Questions relating to the work process contributed significantly to the classification of prenatal care as intermediate according to the IPR/Pre-Natal. IPR/Pre-Natal classification categories were consistent to detect prematurity, insufficient weight at birth and absence of exclusive breastfeeding. The IPR/Pre-Natal index effectively incorporated quantitative and qualitative elements for the assessment of pre-natal care.

Factors Affecting Adequate Prenatal Care and the Prenatal Care Visits of Immigrant Women to Taiwan

This paper investigates prenatal care utilization, identifies factors affecting the adequacy of prenatal care, and explores the effect of adequate initial timing of prenatal care on total prenatal care visits among Taiwan new immigrant females. Data was obtained from the 2008 Prenatal Care Utilization among Taiwan New Immigrant Females Survey on women who either had at least one preschool-aged child or had delivered their infants but were still hospitalized (N = 476). The Adequacy of Prenatal Care Utilization Index was applied to rate the prenatal care adequacy. The logistic regression model was used to investigate factors associated with the adequacy of prenatal care utilization, and the linear regression model was estimated to identify the impact of influential factors on the prenatal care usage. Females' nationality, employment, and transportation convenience increased the likelihood of receiving adequate prenatal care. Having adequate initial timing of prenatal care was found to be positively related to the frequency of prenatal care visits. Prenatal care utilization can be affected by factors within the health care system and by characteristics of the population; therefore, a measure of prenatal care utilization cannot distinguish these factors but reflects the result of all of them in varying combinations.

Inadequate Prenatal Care Utilization and Risks of Infant Mortality and Poor Birth Outcome: A Retrospective Analysis of 28,729,765 U.S. Deliveries over 8 Years

To evaluate the association between adequacy of prenatal care utilization and risk of fetal and neonatal mortality and adverse outcomes. We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all deliveries in the United States between 1995 and 2002. Inclusion criteria were singleton births ≥22 weeks of gestation with no known congenital malformation. Inadequate prenatal care was defined according to the Adequacy of Prenatal Care Utilization Index, and its effect on fetal and neonatal death was estimated using unconditional logistic regression analysis adjusting for maternal age, race, education, and other confounding variables. During our 8-year study period, 32,206,417 births occurred, 28,729,765 (89.2%) of which met inclusion criteria. Inadequate prenatal care utilization occurred in 11.2% of expectant mothers, more commonly among women ≤20 years, black non-Hispanic and Hispanic women, and those without high school education. Relative to adequate care, inadequate care was associated with increased risk of prematurity 3.75 (3.73 to 3.77), stillbirth 1.94 (1.89 to 1.99), early neonatal dearth 2.03 (1.97 to 2.09), late neonatal death 1.67 (1.59 to 1.76), and infant death 1.79 (1.76 to 1.82). Risk of prematurity, stillbirth, early and late neonatal death, and infant death increased linearly with decreasing care. Given the population effect of this association, public health initiatives should target program expansion to ensure timely and adequate access, particularly for women ≤20 years, Black non-Hispanic and Hispanic women, and those without high school education.