Good Prenatal Care Research Articles

INHALANT ABUSE IN PREGNANCY

Information from a variety of sources suggests the possibility of adverse effects of maternal inhalant abuse, although a well-controlled, prospective study in this area has not been conducted. One source of this concern is the data from occupational exposure to some of the abused solvents, specifically toluene and TCE, with numerous reports suggesting increased spontaneous abortion and fetal malformations. There are also data suggesting decreased fertility and an increased risk for spontaneous abortion in health care workers exposed to nitrous oxide. The relevance of these studies to problems of inhalant abuse is not clear. Although the chemicals involved are the same, there are many differences in the exposure parameters, the populations exposed, and the types of associated risk factors. Nonetheless, there are more than 100 cases reported in the literature of children born to solvent-abusing mothers. Many of these children were small at birth, and some have craniofacial abnormalities not unlike that seen in children with FAS. In the few studies reporting the findings of follow-up in these children, some evidence has been obtained for retardation in growth and development and for residual deficits in cognitive, speech, and motor skills. Clearly, more research is needed to rule out the concomitant risk factors and to identify specific chemicals and patterns of use associated with adverse effects. Animal studies provide more direct evidence that prenatal exposure to toluene or TCE can produce reduced birth weights, occasional skeletal abnormalities, and delayed neurobehavioral development, even under conditions designed to mimic inhalant abuse patterns. Additional research is needed to identify other chemicals with adverse effects, critical periods of exposure, effects of combinations of inhalants, or interactions with drugs of abuse. The research literature seems sufficient to alert clinicians to possible problems in patients who abuse inhalants while pregnant. Diagnosis and good prenatal care for these women are important. The evidence for neonatal withdrawal is limited at this time; however, infants born to women who have recently used inhalants should be observed carefully for an alcohol-like withdrawal syndrome. Although it is not possible to link a specific birth defect or developmental problem in the child of an inhalant abuser to prenatal exposure to a specific chemical, it is clear that inhalant abuse and its associated lifestyle place children at increased risk. A wider appreciation of this is needed among health care professionals and the general public.

Maternal Weight Gain Timing: Causes and Consequences

LEARNING OUTCOME: The reader will be able to describe the two maternal weight gain timing patterns and state the one factor significantly related to the pattern.The purpose of the study was to first identify maternal gain timing patterns. If distinct patterns were identified, then relationships of maternal variables and pregnancy outcomes were to be examined with the goal of early identification of risk factors through a simple predictor-weight change. Data were collected retrospectively from medical records of 100 pregnant women who received prenatal care in a rural health department. Sixty women of the 100 entered prenatal care by the 13th week of gestation, had at least eight prenatal care visits, and had at least one documented weight measure per trimester. Cluster analysis of the weight data identified two distinct patterns of weight gain, one linear and one curvilinear. Chi-square and analysis of variance measured the relationship of variables to the pattern. The single significant distinction between the two patterns was prepregnancy body mass index (BMI). A mean BMI of 21 was associated with the linear pattern while a mean BMI of 30.4 was associated with the curvilinear pattern. No other recorded variables were significantly associated with a pattern. Failure to identify more patterns and relationships of patterns to risk factors during pregnancy may be due to healthy subjects with good prenatal care and few complications during pregnancy with good outcomes of the pregnancies. Further study of maternal weight gain timing, especially in high risk groups, is needed to identify predictors of problems and allow early intervention.

Neonatology

Health care for newborns is under close scrutiny in this unsettling era of health system reform. Length of hospital stay for mothers and their newborns continues to shorten, antenatal corticosteroids improve outcome for premature infants and decrease overall costs, and survival of infants born at less than 25 weeks of gestation has improved, but morbidity is high, causing many to question the cost-effectiveness of advanced technologies. Ironically, early discharge after birth originally was demanded by women who wanted alternatives to a "standard" hospital delivery.¹In 1980, the American Academy of Pediatrics (AAP) defined "early discharge" as a stay of 48 hours after an uncomplicated vaginal delivery and "very early discharge" as a stay of less than 24 hours. Eligibility guidelines were outlined as uncomplicated full-term pregnancy with good prenatal care, follow-up care arranged, and desire for early discharge. Subsequently, health insurers began to seek significant cost savings by refusing

Recurrence risk of low birthweight deliveries among women with a prior very low birthweight delivery.

To estimate the risk of repeat low birthweight deliveries among women whose first child was very low birthweight (less than 1500 g), a retrospective cohort of women who had their first and second children in Washington state between 1984 and 1991 was studied. After adjustment for potential confounding factors, a woman whose first infant was very low birthweight experienced an 11.5-fold increased risk of delivering a low birthweight (less than 2500 g) second infant (relative risk 11.5, 95% confidence interval 5.4 to 24.4). Women with a very low birthweight first infant also had a significantly increased risk of repeat very low birthweight infant (p < 0.0001). Women with a previous very low birthweight delivery are at increased risk of repeat low and very low birthweight infants. This high-risk group may benefit from education regarding recurrence risk and modification of factors associated with low birthweight, as well as good prenatal care.

SEVERE ESOPHAGITIS IN A NEWBORN INFANT

SEVERE ESOPHAGITIS IN A NEWBORN INFANT

RISK OF PREMATURITY AND NEONATAL RESPIRATORY DISEASE ASSOCIATED WITH MATERNAL HIV INFECTION. † 1354

We sought to determine the impact of HIV in pregnancy on rates of prematurity, low birth weight (LBW), and neonatal respiratory morbidity in the offspring of HIV positive mothers. From 1990 to 1994, 599 neonates born to HIV positive mothers (51% black, 12% white, 31% Hispanic, 6% others) were enrolled at five centers in the U.S. Of the 599, 92 were HIV positive, 454 were HIV negative, and 53 died or were lost to followup. Incidence of respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), meconium aspiration syndrome (MAS), and neonatal pneumonia was compared to anticipated rates for HIV unexposed neonates of comparable gestation and birth weight. Rates of prematurity (<37 weeks), LBW (<2.5 kg), and VLBW (<1.5 kg) were 19, 17.7, and 3.3%, respectively in the infants of HIV positive mothers, greatly exceeding comparable rates for the U.S. population, corrected for race. The incidence of RDS was 3% (17/599) which coincided with the anticipated rate after adjusting for prematurity and birth weight. Of 16 infants <1.5 kg, 31% (5/16) developed BPD. Only 3/599 infants developed mild MAS and none had documented neonatal pneumonia. Lower gestational age (weeks) was associated with increased odds of HIV infection (p=0.01) in the infants after adjusting for race. We conclude that 1) infants born to HIV positive mothers exhibit very high prematurity and LBW rates; 2) the odds of prematurity are higher in infected (vs uninfected) infants; and 3) the incidence and severity of neonatal respiratory morbidity are no higher than available data from HIV unexposed neonates. We speculate that good prenatal and neonatal care can minimize respiratory morbidity in this high risk population.

Newborn Infant With Multiple Purple Skin Nodules

REPORT OF A CASE A 25-year-old white woman (gravida 2, para 1, aborta 1) was delivered of a girl at 39 weeks' gestation. The mother had good prenatal care, was rubella immune, and had no history of radiation exposure, or drug or alcohol abuse. A primary cesarean section was done for fetal distress, and the amniotic fluid was meconium stained. Apgar scores were 7 at 1 minute, 8 at 5 minutes, and 9 at 10 minutes. Physical examination revealed a 3.3-kg baby, with a temperature of 36.8°C, pulse of 156 beats per minute, and respiratory rate of 60 per minute. The entire body was covered by multiple pink to purple papules and nodules varying from 0.3 to 1.5 cm in diameter (Figure 1). Hepatosplenomegaly was present. The chest radiograph revealed bilateral diffuse pulmonary infiltrates. Initial laboratory studies disclosed the following: hemoglobin, 160 g/L; hematocrit, 0.5; leukocytes, 204×109/L, with

Decreasing perinatal mortality: unchanged infantile spasm morbidity.

The present study examined whether changes in the incidence of infantile spasms could be used to evaluate changes in the quality of pre- and perinatal care over time. 107 children in 1960 to 1976, and 102 in 1977 to 1991, developed infantile spasms in southern Finland. The number of small-for-gestational age (SGA) infants and infants with neonatal hypoglycaemia decreased significantly. Brain malformations, malformation syndromes and patients with tuberous sclerosis increased; this probably reflects the development of more refined neuroradiological screening methods. SGA infants are probably more apt to develop infantile spasms than preterm infants appropriate for gestational age. Early prenatal factors seem to play a major role in the genesis of infantile spasms. Little can be done to reduce the incidence of infantile spasms, but every effort should be made to reduce the number of SGA infants by good prenatal care. Treatment of hypoglycaemia is important because infantile spasms might be preventable in these infants.

Teenage pregnancy: are teenagers a high risk group?

To study health profile of pregnant teenagers and their pattern of utilization of primary health care services in comparison with pregnant women aged 20–35 years in Abha, Saudi Arabia. Study design: A cohort of 1938 Saudi pregnant women (214 teenagers less than 20 years and 1724 aged 20–35 years) was selected by stratified random sampling technique. They were screened for anemia and hypertension using WHO criteria and followed until delivery to observe the method of delivery. The prevalence of anemia (9.6% and 12.0%, respectively) and hypertension (1.1% and 3.5%, respectively) was not significantly different among primigravida of both age groups. The same trend was observed among multigravida. Follow-up showed that the rate of abnormal deliveries among primigravida of both groups was not significantly different, and even lower among multigravida teenagers. Pregnant women in both groups had similar average prenatal visits (6.6 ± 1.1 and 6.7 ± 1.2 respectively, P < 0.05) and the majority contacted the primary health care center early in pregnancy (87.4% and 88.9%, respectively, P < 0.05). These results indicate that pregnant teenagers are not a high risk group if good prenatal care is provided.

Long-Term Contraceptives in the Criminal Justice System

Three weeks after Norplant was approved by the US Food and Drug Administration it was incorporated into the sentence imposed upon a woman convicted of child abuse. It became quickly apparent that this long-acting contraceptive device created to expand the degree of womens reproductive freedom could also be a tool of the state. The Illinois legislature has prohibited contraceptive sentencing but the practice could be legally permissible in other jurisdictions. The author considers whether the approach can be justified on moral and policy grounds to conclude that long-term contraceptives and other punitive measures to solve the problems of abused and neglected children are shortsighted at best. Contraceptive sentencing can have only the most minimal impact upon the incidence of child abuse and neglect. A governmental system which was really serious about protecting children from abuse and neglect would include a probation office with enough employees to implement all types of court-ordered probation conditions high-quality counseling and education for overwhelmed parents help for substance-abusing parents and job and educational training for those in need of employment a child protective services system which responds promptly to reports of abuse and neglect teacher training programs on the detection of children at risk regular health care by professionals familiar with the signs of abuse and neglect and good prenatal care and full family planning services for poor women. Energies should be directed toward developing and supporting such a system.

Health Effects of Adolescent Pregnancy: Implications for Social Workers

Adolescent pregnancy carries significant risks to the health of the pregnant adolescent and her child. These risks, which include pregnancy complications, low birth weight, and infant mortality, are due in large part to the behavior of the adolescent and her socioeconomic circumstances. Early and consistent use of health care can minimize risks by permitting the detection and management of serious problems. Human service professionals should use every opportunity to encourage good prenatal care, while keeping in mind the developmental and personal needs of the pregnant adolescent.

Barriers to Prenatal Care Among Low-Income Women in New York City

Postpartum in-hospital interviews with 496 low-income women in New York City revealed that attitudinal and motivational barriers as well as financial obstacles are significant impediments to timely initiation of prenatal care. The two most common reasons cited by these women in explaining why they had obtained prenatal care late or not at all were motivational items: "feeling depressed and not up to going for care" and "needing time and energy to deal with other problems." In logistic regression analyses, receipt of late or no prenatal care was significantly associated with the latter motivational barrier, along with the cost of care, having no health insurance, being Hispanic, being a substance abuser and holding negative attitudes toward the use of prenatal care.

Maternal Abuse of Cocaine and Heroin-Reply

In Reply .—The problems that Dr Maynard has identified are largely inescapable when studying a population that has little or no contact with the medical system prior to delivery. We entirely agree that questioning and repeated drug testing throughout the course of might have enabled us to identify and quantitate maternal drug use more accurately. However, the majority of the women using drugs in this study had little or no prenatal care. While studies of women using drugs who receive good prenatal care may address this limitation of our study, we suspect that there may be some substantial differences between the population of women who seek routine prenatal care and those who do not. Given the fact that patterns of drug use are likely to change during the duration of pregnancy and the lack of adequate markers for quantitating drug use, we could not determine the quantity of drugs used

THE SAFE MOTHERHOOD INITIATIVE: A CALL TO ACTION

A conference on Safe Motherhood, convened in Nairobi in February 1987 by the World Bank, World Health Organization, and United Nations Fund for Population Activities, has issued a call to reduce maternal mortality in developing countries by 50% in 1 decade. Of the 500,000 maternal deaths that occur each year, 99% are in developing countries. This has been a seriously neglected problem, largely because its victims are those with the least power and influence in society--they are poor, rural peasants, and female. The roots of mush maternal mortality lie in discrimination agianst women, in terms of legal status and access to education, financial resources and health care, including family planning. It is essential that all women are ensured access to maternal health and family planning services, especially obstetric care for life-threating conditions such as obstructed labor, eclampsia, toxemia, infection, and complications from spontaneous and induced abortion. The primary health care system at the district and subdistric leveles needs strengthening to provide adequate prenatal care and family planning services and to upgrade district hospitals and maternity centers so they can perform emergency care in pregnancy and childbirth. Since illegal abortion from unwanted pregnancy accounts for 25-50% of maternal deaths, access to family planning services and safe procedures is particularly important. In his remarkes to the conference, Halfdan Mahler, Director-General of WHO, outlined a 4-part strategy to combat maternal mortality: 1) adequate primary health care and an adequate share of available food for females from infancy to adolescence, and universally available family planning; 2) good prenatal care, including nutrtion, with early detection and referral of those at high risk; 3) the assistance of a trained person at all births; and 4) access to the essential elements of obstetric care for women at higher risk.

Maternal Disease as a Consideration in Lactation Management

Breastfeeding for mothers with chronic medical conditions presents important medical decisions for the primary physician. The issues need to be considered in light of the chronic disease, the physiological process of lactation, and the individual Mother for whom breastfeeding is very important. Management plans need to be based on adequate information and coordinated by the mother's physician and the pediatrician.

Extent of pregnancy supervision in Bavaria and measurement of its effectiveness

Perinatal mortality is high in the Federal Republic of Germany when compared with that in the Scandinavian countries, and it is often claimed that this is due to the unsatisfactory utilisation of prenatal care examinations in this country. Good prenatal care is characterised by the fact that it starts early, that it is carried out intensively, and that it is flexibly adapted to the individual risk situation. Of 83,308 pregnant women covered 1981 by the Bavarian Perinatal Analysis Inquiry, 65.5% had consulted the doctor for the first time before the 13th week of pregnancy, whereas 1.8% consulted the doctor after the 36th week. 53.1% were examined 10 or more times. Every 8th pregnant woman (12.8%) had omitted at least two or more consultations compared with the recommendations for prenatal care and independent of the onset of the care programme. Factors exercising a positive influence on perinatal care resulted in better utilisation, and vice versa. The care programme was frequently neglected by primigravidae who where less than 16 years old, by multigravidae, unmarried mothers and foreigners. Data on the effectiveness of prenatal care are supplied by the Bavarian Perinatal Inquiry Data especially in the analysis of risk-free pregnancies. The later perinatal care was instituted, the more frequent were risk factors at birth. On the average, birth risk was seen after every 5th risk-free pregnancy (21.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Community support for adolescent parents and their children: The parent-to-parent program in Vermont

Most adolescent parents now receive good prenatal and neonatal medical care, some receive limited amounts of parenting instruction, and increasing numbers can participate in school completion programs. But few programs address the social isolation and broad developmental disruptions that often accompany adolescent parenthood. This article describes the implementation and short-term effects of one program that does strive to meet adolescents' long-term, broad support needs. The Parent-to-Parent program is a home-based program designed to enhance the ability of adolescent parents to meet their young children's and their own developmental needs. Through long-term home visiting by specially trained local volunteers, parent group meetings, and work with local human service institutions, the program strives to (1) enhance the quality of parent-child interaction; (2) enhance the parents' ability to locate and acquire services that will help them meet basic needs; (3) enhance parent and child involvement in community life; and (4) help the parents become more aware of their own options for the future, and more capable of implementing the plans they make.

Reduction in perinatal mortality in developing countries: experiences from Zululand.

The principles governing the reduction of perinatal mortality are: 1) provision of good prenatal care; 2) safe delivery at term; and 3) the maintenance of infant nutrition and the prevention of infection. The author speaks of her experiences in a rural area of the Zulu country of South Africa. Cultural attitudes and beliefs are very different in rural Africa than they are in developed countries. Zulu mothers have a sense of fatalism--the baby is not ill it just dies. When the author began her work in 1945 the small hospital in the Nqutu district of Zululand was largely ignored. The people are poor; the roads bad. The author learned to build confidence. She tried to reach the remotest parts of the district. 11 centers were established throughout the 700 square miles served. The visiting team consisted of a doctor a nurse and a dispenser-driver. Prenatal exams were done in these clinics. They became places where mothers at particular risk could be selected. High-risk factors made hospital delivery essential. A number of the clinics were tended by a resident nurse. She had a single labor ward and a lying-in ward for delivery of low-risk cases. Training was begun for midwives in diagnosis pelvic assessment and decision-making. Also learned was application of the vacuum extractor resuscitation of the newborn setting up scalp vein infusions and taking blood for bilirubin estimation. Recognition of low-weight babies is an important part of midwife work. After initial training midwives returned for refresher courses. Breastfeeding must be taught even to Zulu mothers. This is done in the hospital.

Dental Management of the Pregnant Patient

The pregnant patient presents several considerations for providing dental treatment. Among these are that there are two persons involved in the dental treatment of a pregnant woman, the woman and the baby. Each presents a different set of problems. The mother basically presents no difficult problems for dental treatment. She needs to have routine dental treatment provided. All procedures can be done. Because of the fetus, certain precautions in the use of drugs and radiographs must be taken. If it is determined in taking the history that a person may be pregnant and she is not seeing an obstetrician, the dentist should urge her to see one at her earliest convenience. It is well documented that early and good prenatal care decreases the risk to the mother and to the fetus. Diabetes, hypertension, and anemias are frequently associated with pregnancy and produce a threat to the developing fetus. These diseases, along with any other systemic diseases and infections that pose threats to either the mother or the fetus, are normally detected with good prenatal care.

Alcohol use and iron status in pregnant women.

Iron status, assessed by ferritin (ng/ml), transferrin saturation (%), and hemoglobin (g/100 ml), was examined in a sample of 1398 women from blood samples drawn at their first prenatal visit and in 712 of these women later at their 32-week prenatal visit. Self-reported alcohol use (average ounces of absolute alcohol consumed per day around the time of conception) was not systematically related to iron status. Furthermore, the proportion of iron-depleted or anemic women did not vary according to different levels of alcohol use. An exception is noted in a small group of nine very heavy drinkers, reporting eight or more drinks per day, who, at 32 weeks gestation, had a higher proportion of iron depletion but not anemia. It was concluded that at least in a sample of primarily middle class women receiving good prenatal care, iron depletion and/or anemia probably do not explain the alcohol-related adverse pregnancy outcomes that have been reported previously. Nevertheless, results from several very heavy drinkers suggest that the iron status of pregnant alcoholic women should be investigated further.