Rates Of Inadequate Prenatal Care Research Articles

Race and Place Matter: Inequity in Prenatal Care for Reservation-Dwelling American Indian People.

Early initiation and consistent use of prenatal care is linked with improved health outcomes. American Indian birthing people have higher rates of inadequate prenatal care (IPNC), but limited research has examined IPNC among people living on American Indian reservations. The current study uses birth certificate data from the state of Montana (n = 57,006) to examine predictors of IPNC. Data on the community context is integrated to examine the role of community health in mediating the associations between reservation status and IPNC. Results suggest that reservation-dwelling birthers are more likely to have IPNC, an association partially mediated by community health. Odds of IPNC are higher for reservation-dwelling American Indian people compared to reservation-dwelling White birthers, highlighting intersecting inequalities of race and place.

1135: Increasing rate of no prenatal care in pregnancies complicated by Hepatitis C in the US

Despite efforts to expand access to prenatal care under the umbrella of Healthy People 2020, certain populations of women continue to be at risk for not accessing prenatal care. We aim to describe the relationship between no prenatal care (PNC) with pregnancies complicated by Hepatitis C in the US. Population-based retrospective cohort study of all US live births from 2012-2016 using vital statistic records. Quantity of PNC is recorded on the US certificate of live birth as “total number of prenatal visits” for the pregnancy. No PNC was defined as zero prenatal visits, and inadequate PNC defined as < 50% of recommended number of visits adjusted for gestational age at birth using the Kessner Index. Presence of Hepatitis C (Hep C) is also recorded on the US birth certificate. Frequency of no PNC was calculated per year among all live births (20-42 wks) and compared to births to mothers with Hep C. The rate of no PNC overall during the study period was 1.47%, increasing from 1.36% in 2012 to 1.58% in 2016, p< 0.001. Of the 19,547,691 births analyzed, 0.29% mothers had Hep C. Among births to mothers with Hep C, the rate of no PNC rose from 1.21% to 6.31%, greater than 5-fold increase, p< 0.001. The largest annual increase of no PNC with Hep C was in 2014 with a 3.5-fold increase over 1 year, an increase not similarly observed in the overall population (figure). Rates of inadequate prenatal care similarly increased in women with Hep C during the study period. The overall rate of no PNC in the US rose slightly from 2012-2016. However, the rate increased more dramatically among women with Hep C. This may be related to higher rates of maternal substance use disorders among women with Hep C, particularly intravenous drug use. Mothers’ perceptions of negative legal ramifications of having illicit drug use identified during pregnancy may lead to avoidance of prenatal care. Public health initiatives should focus on improving access to care for women with high-risk pregnancy conditions, especially as rates of substance abuse disorders and Hepatitis C are on the risk in the US.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prenatal care among mothers involved with child protection services in Manitoba: a retrospective cohort study.

Prenatal care is one of the most widely used preventive health services; however, use varies substantially. Our objective was to examine prenatal care among women with a history of having a child placed in out-of-home care, and whether their care differed from care among women who did not. We used linkable administrative data to create a population-based cohort of women whose first 2 children were born in Manitoba, Canada, between Apr. 1, 1998, and Mar. 1, 2015. We measured the level of prenatal care using the Revised Graduated Prenatal Care Utilization Index, which categorizes care into 5 groups: intensive, adequate, intermediate, inadequate and no care. We compared level of prenatal care for women whose first child was placed in care with level of prenatal care for women who had no contact with care services, using 2 multinomial logistic regression models to calculate odds ratios (ORs). In a cohort of 52 438 mothers, 1284 (2.4%) had their first child placed in out-of-home care before conception of their second child. Mothers whose first child was placed in care had much higher rates of inadequate prenatal care during the pregnancy with their second child than mothers whose first child was not placed in care (33.0% v. 13.4%). The odds of having inadequate rather than adequate prenatal care were more than 4 times higher (OR 4.29, 95% CI 3.68 to 5.01) for women who had their first child placed in care than for women who did not have their first child placed in care. Mothers with a history of having a child taken into care by the child protection services system are at higher risk of having inadequate or no prenatal care in a subsequent pregnancy compared with mothers with no history of involvement with child protection services.

Prenatal care of women who give birth to children with fetal alcohol spectrum disorder in a universal health care system: a case-control study using linked administrative data.

Few studies have investigated prenatal care use among women who use alcohol during pregnancy. The objective of this study was to investigate rates of prenatal care usage of women who have given birth to children with fetal alcohol spectrum disorder (FASD). We conducted a case-control study of women with children born in Manitoba between Apr. 1, 1984, and Mar. 31, 2012, with follow-up until 2013, using linkable administrative data. The study group included women whose child(ren) was (were) diagnosed with FASD (n = 702) between Apr. 1, 1999, and Mar. 31, 2012, at a centralized diagnostic clinic. The comparison group included women whose child(ren) did not have an FASD diagnosis (n = 2097), exact matched on the index child's birthdate, postal code and socioeconomic status. Adequacy of prenatal care was defined using the Revised Graduated Prenatal Care Utilization Index. Women in the study group had lower socioeconomic status than women in the comparison group and were more likely to have mental disorders and involvement with the child welfare system. Rates of inadequate prenatal care were higher among women in the study group (adjusted relative risk 2.47, 95% confidence interval [CI] 2.08-2.94), as were rates of no prenatal care (adjusted relative risk 3.55, 95% CI 2.42-5.22). In the study group, 41% of women accessed inadequate or no prenatal care, and 59% received intermediate, adequate or intensive prenatal care. Women who give birth to children with FASD have higher rates of inadequate prenatal care and significant social complexities. Socioeconomic disparities in the use of prenatal care should be addressed; multisector interventions are needed that facilitate the uptake of prenatal care by high-risk women who use alcohol.

Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba

BackgroundEnsuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care.MethodsWe studied women giving birth in Manitoba from 2004/05–2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information.ResultsOverall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use.ConclusionThe rate of inadequate prenatal care in Manitoba ranged from 10.5–12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

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.

Partners in Inner‐City Integrated Prenatal Care (PIIPC) Project in Winnipeg, Canada: Effect on Rates of Inadequate Prenatal Care at a Population Level

Partners in Inner‐City Integrated Prenatal Care (PIIPC) Project in Winnipeg, Canada: Effect on Rates of Inadequate Prenatal Care at a Population Level

Perceptions of barriers, facilitators and motivators related to use of prenatal care: A qualitative descriptive study of inner-city women in Winnipeg, Canada.

Objective:The objective of this qualitative descriptive study was to explore the perceptions of women living in inner-city Winnipeg, Canada, about barriers, facilitators, and motivators related to their use of prenatal care.Methods:Individual, semi-structured interviews were conducted in person with 26 pregnant or postpartum women living in inner-city neighborhoods with high rates of inadequate prenatal care. Interviews averaged 67 min in length. Recruitment of participants continued until data saturation was achieved. Inductive content analysis was used to identify themes and subthemes under four broad topics of interest (barriers, facilitators, motivators, and suggestions). Sword’s socio-ecological model of health services use provided the theoretical framework for the research. This model conceptualizes service use as a product of two interacting systems: the personal and situational attributes of potential users and the characteristics of health services.Results:Half of the women in our sample were single and half self-identified as Aboriginal. Participants discussed several personal and system-related barriers affecting use of prenatal care, such as problems with transportation and child care, lack of prenatal care providers, and inaccessible services. Facilitating factors included transportation assistance, convenient location of services, positive care provider qualities, and tangible rewards. Women were motivated to attend prenatal care to gain knowledge and skills and to have a healthy baby.Conclusion:Consistent with the theoretical framework, women’s utilization of prenatal care was a product of two interacting systems, with several barriers related to personal and situational factors affecting women’s lives, while other barriers were related to problems with service delivery and the broader healthcare system. Overcoming barriers to prenatal care and capitalizing on factors that motivate women to seek prenatal care despite difficult living circumstances may help improve use of prenatal care by inner-city women.

Association Between Insurance and Adequacy of Prenatal Care [257

INTRODUCTION: Obese women and Medicaid recipients have an increased risk of poor pregnancy outcomes, which has been thought to be the result of inadequate prenatal care. However, our prior work demonstrated that maternal obesity is associated with an improved adequacy of prenatal care in our population. Although obesity was associated with increased use of ultrasound services, this alone did not explain the improvement in prenatal care adequacy associated with obesity. We sought to further examine whether payer status influences prenatal care adequacy. METHODS: From a University of Rochester database of deliveries from January 2009 to December 2011, participants were categorized by body mass index (BMI, calculated as weight (kg)/[height (m)]2) as normal weight (BMI 18.5–24.9), overweight (BMI 25–29.9), and obese (BMI 30, subdivided as class I, II, III). Prenatal care adequacy was evaluated using the Kotelchuck Index. Payer status was defined as private, Medicaid, and other (tricare, self-pay). χ2 was used for univariate comparisons and logistic regression for multivariable testing. RESULTS: Of 7,090 deliveries, inadequate prenatal care was more common in both Medicaid (32.7%; odds ratio [OR] 1.24, 95% confidence interval [CI] 1.11–1.38) and other insurance groups (43.4%; OR 1.95, 95% CI 1.13–3.37) compared with private insurance (28.2% inadequate). After adjusting for age, race, education, obesity class, diabetes, and hypertension, payer status remained a significant predictor of inadequate prenatal care (Medicaid OR 1.18, 95% CI 1.03–1.35; “other” OR 1.85, 95% CI 1.05–3.24). CONCLUSION: Medicaid and other nonprivate insurance payer statuses are associated with higher rates of inadequate prenatal care compared with private insurance regardless of obesity status and potential confounders. The reason for less adequate care in these groups is unclear.

Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case-control study.

BackgroundThe reasons why women do not obtain prenatal care even when it is available and accessible are complex. Despite Canada’s universally funded health care system, use of prenatal care varies widely across neighborhoods in Winnipeg, Manitoba, with the highest rates of inadequate prenatal care found in eight inner-city neighborhoods. The purpose of this study was to identify barriers, motivators and facilitators related to use of prenatal care among women living in these inner-city neighborhoods.MethodsWe conducted a case–control study with 202 cases (inadequate prenatal care) and 406 controls (adequate prenatal care), frequency matched 1:2 by neighborhood. Women were recruited during their postpartum hospital stay, and were interviewed using a structured questionnaire. Stratified analyses of barriers and motivators associated with inadequate prenatal care were conducted, and the Mantel-Haenszel common odds ratio (OR) was reported when the results were homogeneous across neighborhoods. Chi square analysis was used to test for differences in proportions of cases and controls reporting facilitators that would have helped them get more prenatal care.ResultsOf the 39 barriers assessed, 35 significantly increased the odds of inadequate prenatal care for inner-city women. Psychosocial issues that increased the likelihood of inadequate prenatal care included being under stress, having family problems, feeling depressed, “not thinking straight”, and being worried that the baby would be apprehended by the child welfare agency. Structural barriers included not knowing where to get prenatal care, having a long wait to get an appointment, and having problems with child care or transportation. Attitudinal barriers included not planning or knowing about the pregnancy, thinking of having an abortion, and believing they did not need prenatal care. Of the 10 motivators assessed, four had a protective effect, such as the desire to learn how to protect one’s health. Receiving incentives and getting help with transportation and child care would have facilitated women’s attendance at prenatal care visits.ConclusionsSeveral psychosocial, attitudinal, economic and structural barriers increased the likelihood of inadequate prenatal care for women living in socioeconomically disadvantaged neighborhoods. Removing barriers to prenatal care and capitalizing on factors that motivate and facilitate women to seek prenatal care despite the challenges of their personal circumstances may help improve use of prenatal care by inner-city women.

Migrant Women’s Utilization of Prenatal Care: A Systematic Review

Our objectives were to determine whether migrant women in Western industrialized countries have higher odds of inadequate prenatal care (PNC) compared to receiving-country women and to summarize factors that are associated with inadequate PNC among migrant women in these countries. We conducted searches of electronic databases (MEDLINE, EMBASE, and PsycINFO), reference lists, known experts, and an existing database of the Reproductive Outcomes And Migration international research collaboration for articles published between January, 1995 and April, 2010. Title and abstract review and quality appraisal were conducted independently by 2 reviewers using established criteria, with consensus achieved through discussion. In this systematic review of 29 studies, the majority of studies demonstrated that migrant women were more likely to receive inadequate PNC than receiving-country women, with most reporting moderate to large effect sizes. Rates of inadequate PNC among migrant women varied widely by country of birth. Only three studies explored predictors of inadequate PNC among migrant women. These studies found that inadequate PNC among migrant women was associated with being less than 20 years of age, multiparous, single, having poor or fair language proficiency, education less than 5 years, an unplanned pregnancy, and not having health insurance. We concluded that migrant women as a whole were more likely to have inadequate PNC and the magnitude of this risk differed by country of origin. Few studies addressed predictors of PNC utilization in migrant women and this limits our ability to provide effective PNC in this population.

Predictors of inadequate prenatal care in methamphetamine-using mothers in New Zealand and the United States.

This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socioeconomic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.

Trends in Perinatal and Infant Health Disparities Between Rural American Indians and Alaska Natives and Rural Whites

We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time. We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births. Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985-1987, 36.3%; 1995-1997, 26.3%) and postneonatal death (1985-1987, 7.1 per 1000; 1995-1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985-1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995-1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985-1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995-1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted. Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group.

Inadequate prenatal care and its association with adverse pregnancy outcomes: A comparison of indices

BackgroundThe objectives of this study were to determine rates of prenatal care utilization in Winnipeg, Manitoba, Canada from 1991 to 2000; to compare two indices of prenatal care utilization in identifying the proportion of the population receiving inadequate prenatal care; to determine the association between inadequate prenatal care and adverse pregnancy outcomes (preterm birth, low birth weight [LBW], and small-for-gestational age [SGA]), using each of the indices; and, to assess whether or not, and to what extent, gestational age modifies this association.MethodsWe conducted a population-based study of women having a hospital-based singleton live birth from 1991 to 2000 (N = 80,989). Data sources consisted of a linked mother-baby database and a physician claims file maintained by Manitoba Health. Rates of inadequate prenatal care were calculated using two indices, the R-GINDEX and the APNCU. Logistic regression analysis was used to determine the association between inadequate prenatal care and adverse pregnancy outcomes. Stratified analysis was then used to determine whether the association between inadequate prenatal care and LBW or SGA differed by gestational age.ResultsRates of inadequate/no prenatal care ranged from 8.3% using APNCU to 8.9% using R-GINDEX. The association between inadequate prenatal care and preterm birth and LBW varied depending on the index used, with adjusted odds ratios (AOR) ranging from 1.0 to 1.3. In contrast, both indices revealed the same strength of association of inadequate prenatal care with SGA (AOR 1.4). Both indices demonstrated heterogeneity (non-uniformity) across gestational age strata, indicating the presence of effect modification by gestational age.ConclusionSelection of a prenatal care utilization index requires careful consideration of its methodological underpinnings and limitations. The two indices compared in this study revealed different patterns of utilization of prenatal care, and should not be used interchangeably. Use of these indices to study the association between utilization of prenatal care and pregnancy outcomes affected by the duration of pregnancy should be approached cautiously.

Social Inequalities in Use of Prenatal Care in Manitoba

ObjectiveAnalysis of regional variations in use of prenatal care to identify individual-level and neighbourhood-level determinants of inadequate prenatal care among women giving birth in the province of Manitoba. MethodsData were obtained from Manitoba Health administrative databases and the 1996 Canadian Census. An index of prenatal care use was calculated for each singleton live birth from 1991 to 2000 (N=149 291). Births were geocoded into 498 geographic districts, and a spatial analysis was conducted, consisting of data visualization, spatial clustering, and data modelling using Poisson regression. ResultsWe found wide variation in rates of inadequate prenatal care across geographic areas, ranging from 1.1% to 21.5%. Higher rates of inadequate care were found in the inner-city of Winnipeg and in northern Manitoba. After adjusting for individual characteristics, the highest rates of inadequate prenatal care were among women living in neighbourhoods with the lowest average family income, the highest proportion of the population who were unemployed, the highest rates of recent immigrants, the highest percentage of the population reporting Aboriginal status, the highest percentage of single parent families, the highest percentage of the population with fewer than nine years of education, and the highest rates of women who smoked during pregnancy. ConclusionsSocial inequalities exist in the use of prenatal care among Manitoba women, despite there being a universally funded health care system. Regional disparities in rates of inadequate prenatal care emphasize the need for further research to determine specific risk factors for inadequate prenatal care in socioeconomically disadvantaged neighbourhoods, followed by provision of effective targeted services.

Moving to Mandatory Medicaid Managed Care in Ohio

Understanding the impacts of Medicaid managed care on pregnant women is critical because Medicaid covers more than a third of all births nationally, many under managed care arrangements. We sought to examine the impacts of mandatory Health Maintenance Organization (HMO) enrollment on prenatal care use, smoking, and birth weight for Medicaid-covered pregnant women in Ohio. Impact estimates are derived from a pre-post design with a comparison group, using Ohio birth certificate data linked to Medicaid enrollment files. Between April 1993 and April 1995 is the baseline period and October 1997 to June 1998 is the post-period. The treatment group consists of deliveries in 6 counties that implemented mandatory HMO enrollment in the mid 1990s; the comparison group consists of deliveries in 4 counties with voluntary HMO enrollment. Medicaid-covered deliveries to 24,799 non-Hispanic white women with no college education living in Ohio. Seven outcomes are analyzed: first trimester care; last trimester or no care; adequate prenatal care; inadequate prenatal care; smoking during pregnancy; and birth weight. Our findings indicate that mandatory HMO enrollment in Ohio's Medicaid program had positive effects on prenatal care and led to reductions in maternal smoking. No effects were found on birth weight. Even with the improvements related to Medicaid managed care, rates of inadequate prenatal care and maternal smoking remain relatively high. Addressing the underlying risk factors that are facing poor women and further expanding public programs may be critical to achieving further progress.