Recommendations For Prenatal Care Research Articles

A Simulation Model of the Effects of Tailored Prenatal Care Delivery on Care Access [ID: 1377136

INTRODUCTION: The Michigan Plan for Appropriate Tailored Healthcare in pregnancy (PATH) recommends tailoring prenatal care delivery to patients’ risk factors for visit number (for low risk: 8–9 visits; for high-risk patients: 12–14 visits) and preferences for care modality (in-person only or hybrid with virtual visits). We used simulation to explore how tailored prenatal care recommendations affect care access. METHODS: A discrete event simulation was created in C++ to assess the operational effects of tailored recommendations in comparison to standard care. Patients enter the system and are divided into low-risk and high-risk categories based on medical conditions. The simulation models dynamic patient arrivals, varied patient classifications, tailored pathways, heterogeneous durations of total care, and patient flow until each patient's pathway ends (eg, childbirth). Metrics captured include patient delays, overbooked appointments, and unused capacity. The model was run with 1,000 replications during a 52-week period with a 10-year warm-up period to reach steady-state equilibrium within the simulation. The IRB designated this analysis of de-identified data exempt. RESULTS: Transitioning to the new prenatal care model reduced mean care delays per patient in all care modalities by 3.5 weeks for low-risk patients (9.79 weeks–6.37 weeks) and 0.4 weeks for high-risk patients (9.8 weeks–9.4 weeks). Tailoring care reduced the percentage of overbooked appointments by an average of 9.4% and the average unused capacity by 7.4%. CONCLUSION: Tailored prenatal care models including telemedicine result in improved operational efficiencies.

Pregnancy-related healthcare utilization among women with multiple sclerosis.

Many studies have investigated pregnancy in women with multiple sclerosis (MS). However, no study has measured prenatal healthcare utilization in women with MS or adherence to follow-up recommendations to improve antenatal care quality. A better knowledge of the quality of antenatal care in women with MS would help identify and better support women with insufficient follow-up. Our objective was to measure the level of compliance to prenatal care recommendations in women with MS using data from the French National Health Insurance Database. This retrospective cohort study included all pregnant women with MS who gave live birth in France between 2010 and 2015. Using the French National Health Insurance Database, follow-up visits with gynecologists, midwives, and general practitioners (GPs) were identified, as well as ultrasound exams and laboratory tests. Based on the Adequacy of Prenatal Care Use and Content and Timing of care in Pregnancy indices, a new tool adapted to the French recommendations was developed to measure and classify the antenatal care trajectory (adequate or inadequate). Explicative factors were identified using multivariate logistic regression models. A random effect was included because women may have had more than one pregnancy during the study period. In total, 4,804 women with MS (N = 5,448 pregnancies ending in live births) were included. When considering only visits with gynecologists/midwives, 2,277 pregnancies (41.8%) were considered adequate. When adding visits with GP, their number increased to 3,646 (66.9%). Multivariate models showed that multiple pregnancy and higher medical density were associated with better adherence to follow-up recommendations. Conversely, adherence was lower in 25-29-year-old and >40-year-old women, in women with very low income, and agricultural and self-employed workers. No visits, ultrasound exams, and laboratory tests were recorded in 87 pregnancies (1.6%). In 50% of pregnancies, women had at least one visit with a neurologist during the pregnancy, and women restarted disease-modifying therapy (DMT) within 6 months after delivery in 45.9% of pregnancies. Many women consulted their GP during pregnancy. This could be linked to a low density of gynecologists but may also reflect the preferences of women. Our findings can help adapt recommendations and healthcare providers' practices according to the women's profiles.

Association Between Compliance With the New WHO-Recommended Frequency and Timing of Antenatal Care Contacts and Receiving Quality Antenatal Care in Cameroon

The objective of this study was to determine whether adherence to the new WHO recommendations for the frequency and timing of antenatal care (ANC) contacts was associated with receiving quality prenatal care in Cameroon. The 2018 Cameroon Demographic and Health Survey yielded a weighted sample of 5,694 women aged 15 to 49 years for analysis. We found that 8.9% of women had at least eight ANC contacts, with 47.3% of those occurring during the first trimester. Overall, 28.3% (95% CI [26.4, 30.3]) of the women received all eight ANC interventions studied. Women who made at least eight ANC contacts prior to delivery had a higher chance of receiving the full set of interventions (AOR = 1.41; 95% CI [1.00, 1.99]). Even among women who started ANC in the second trimester, those who made at least eight contacts were more likely than those who made fewer contacts to receive the full set of interventions. Furthermore, women who had their first contact later in the second (AOR = 0.85; 95% CI [0.72, 0.99]) or third trimester (AOR = 0.33; 95% CI [0.19, 0.57]) were less likely to receive the full set of interventions. According to our findings, Cameroonian women who followed the new global recommendations for prenatal care were more likely to receive quality prenatal care before giving birth. To have a positive pregnancy experience, however, more women must begin ANC in the first trimester and have at least eight contacts with health care providers before delivery.

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians.

Prenatal care is an important preventive service designed to improve the health of pregnant patients and their infants. Prenatal care delivery recommendations have remained unchanged since 1930, when the 12-14 in-person visit schedule was first established to detect preeclampsia. In 2020, the American College of Obstetricians and Gynecologists, in collaboration with the University of Michigan, convened a panel of maternity care experts to determine new prenatal care delivery recommendations. The panel recognized the need to include emerging evidence and experience, including significant changes in prenatal care delivery during the COVID-19 pandemic, pre-existing knowledge of the importance of individualized care plans, the promise of telemedicine, and the significant influence of social and structural determinants of health (SSDoH) on pregnancy outcomes. Recommendations were derived using the RAND-UCLA appropriateness method, a rigorous e-Delphi method, and are designed to extend beyond the acute public health crisis. The resulting Michigan Plan for Appropriate Tailored Healthcare in pregnancy (MiPATH) includes recommendations for key aspects of prenatal care delivery: (1) the recommended number of prenatal visits, (2) the frequency of prenatal visits, (3) the role of monitoring routine pregnancy parameters (blood pressure, fetal heart tones, weight, and fundal height), (4) integration of telemedicine into routine care, and (5) inclusion of (SSDoH). Resulting recommendations demonstrate a new approach to prenatal care delivery that incorporates medical, SSDoH, and patient preferences, to develop individualized prenatal care delivery plans. The purpose of this document is to outline the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.

The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations.

To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare in pregnancy) panel process and key recommendations for prenatal care delivery. We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine). The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices. The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

Adequacy of Prenatal Care in Northeast Brazil: Pilot Data Comparing Attainment of Standard Care Criteria for First-Time Adolescent and Adult Pregnant Women.

BackgroundAdolescent pregnancy is a public health concern worldwide, particularly in low-income settings. Adolescent mothers face higher risks during pregnancy and delivery compared to adult mothers and yet, may also experience worse quality of obstetrical care. This study evaluates adherence to meeting Brazilian recommendations for prenatal care by comparing first-time adolescent versus adult mothers in a rural, low-income setting.MethodsUsing data from the Adolescence and Motherhood Research (AMOR) project, we evaluated adherence to national recommendations as documented in the prenatal cards of 39 adolescents (13–18 years) and 37 adults (23–28 years) from a low-income area in northeast Brazil. Recommendations included ≥6 prenatal consultations, gestational age ≤12 weeks at the first visit, participation in 3 educational activities, 2 serology for syphilis (VDRL) and HIV, 1 Toxoplasmosis serology, 2 urine tests, 2 blood glucose and 2 hemoglobin/hematocrit (Hb/Ht) exams. Chi-square tests were used to compare the proportions of adolescents and adults with a record of these procedures in the prenatal cards.ResultsCompared to adult women, the adolescent group had lower attainment of almost all recommended components of prenatal care compared to the adult group, with statistically significant differences for 2 blood glucose tests (46.2% vs 78.4%; p=0.004), 2 VDRL tests (30.8% vs 54.1%; p=0.040), 2 Hb/Ht exams (35.9% vs 83.8%; p<0.001), and at least 6 consultations (84.6% vs 100%; p=0.013).ConclusionDespite greater health risks of adolescent fertility, the prenatal cards of adolescent mothers presented a poorer record of adherence to recommendations for adequate prenatal care compared to adult mothers from a low-income setting of Brazil. Health policies for both health professionals and the target population are needed to ensure adequacy of prenatal care and appropriate risk reduction for this vulnerable population.

Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study.

To identify the sociodemographic factors and prenatal behavior characteristics associated with unplanned pregnancy. A cross-sectional survey was conducted of mothers of newborns enrolled in a birth cohort in Ribeirão Preto, Brazil. Questionnaires were administered to postpartum women. Multiple logistic regression was used to identify sociodemographic predictors of unplanned pregnancy and to evaluate the association with adherence to prenatal care recommendations. The cohort included 7608 mothers: 7541 (99.1%) answered the interview and 4056 (53.8%) had an unplanned pregnancy. Adolescents were more likely to have an unplanned pregnancy (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.50-2.34) as were women over 40 (OR 1.74; 95% CI 1.22-2.47). Pregnancy during adolescence (OR 1.27; 95% CI 1.09-1.48), being single (OR 7.56; 95% CI 5.98-9.56), having two or more previous births (OR 1.73; 95% CI 1.52-1.97), and being of a lower socioeconomic status were also predictors. Lack or late initiation of prenatal care, attendance at less than six prenatal visits, drinking alcohol, and smoking during pregnancy were associated with unplanned pregnancy. Unplanned pregnancies disproportionately affect women at extremes of age, single, and of low socioeconomic status. These women are less likely to adhere to prenatal care.

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.

Validating a path model of adherence to prenatal care recommendations among pregnant women

ObjectiveTo date, no study has reported a diagrammatic path model that involves patient-provider communication on pregnant women’s adherence to prenatal care recommendations. To bridge this gap, this study aimed to validate a path model to display the direct and indirect influences on adherence to prenatal care recommendations. MethodsA cross-sectional study founded on an evidence-based proposed theoretical framework was conducted among pregnant women (18–45 years) in their second or third trimester (n = 401) in the Midwestern United States. The proposed theoretical framework examined multiple levels of influences. Previously validated instruments were pilot tested and modified. Path analysis was conducted to validate the best-fit path model. ResultsThe path model showed shared decision-making and motivation significantly predicted adherence to prenatal care recommendations and accounted for 10% (R2) of the variance. Cultural competency, interaction, perceived discrimination, and satisfaction accounted for 30% (R2) of the variance of shared decision-making. Patient’s trust, distrust, and self-efficacy accounted for 5% (R2) of motivation’s variance. ConclusionOur work identified the best-fit path model for adherence to prenatal care recommendations. Practice implicationsIncorporating findings from this study could assist prenatal care providers in understanding many complex variables affecting prenatal care, ultimately reducing infant mortality.

Low-dose aspirin in the prevention of pre-eclampsia in China (APPEC study): protocol for a multicentre randomized controlled trial

BackgroundLow-dose aspirin (LDA) has been proposed as a safe and inexpensive prophylactic agent. Studies in European/Western populations have shown promising results indicating that LDA can reduce the occurrence of pre-eclampsia (PE) in women with identifiable risk factors. However, few controlled trials, particularly large randomized controlled trials, have been performed in Asian populations. The aim of this project is to evaluate the effect of LDA for PE prevention on high-risk pregnant women in China, where PE is highly prevalent and the LDA supply status is commonly suboptimal.Methods/designAn open-label, multicentre randomized controlled trial is being conducted at 13 tertiary hospitals in 11 provinces in China. A total of 1000 eligible women with high-risk factors for developing PE according to their medical histories are being randomized into two groups: a control group (n = 500) and an intervention group (n = 500). Women with high-risk factors, such as a history of PE, chronic hypertension, type 1 or 2 diabetes, advanced maternal age, obesity, family history of PE or nulliparity are eligible. The control group is advised to undergo routine examinations, whereas the intervention group undergoes the routine examinations and receives LDA. LDA (100 mg/d) should be prescribed at night, initiating from early pregnancy (12–20 weeks of gestation) and lasting until 34 weeks of gestation. Demographic data and clinical endpoint outcomes, as well as biological samples (e.g., maternal blood, cord blood, amniotic fluid and placental samples), will be collected. The primary outcome is the occurrence of PE, and the secondary outcomes include maternal and neonatal outcomes and maternal biomarker levels.DiscussionThis is the first and largest multicentre randomized controlled trial to assess the effect of LDA in preventing PE in a Chinese population. The results will potentially influence the prenatal care recommendations in China regarding intervention with LDA for PE.Trial registrationClinicalTrials.gov, NCT02797249. Registered on 7 June 2016.

The Impact of Symptoms of Depression and Walking on Gestational Age at Birth in African American Women

BackgroundSymptoms of depression have been related to lower gestational age and preterm birth (<37 completed weeks gestation). Leisure time physical activity may have protective effects on preterm birth; however, less has been published with regard to other domains of physical activity such as walking for a purpose (e.g., for transportation) or the pathways by which symptoms of depression impact gestational age at birth. MethodsThis was a secondary analysis of available data of African American women. Women were interviewed within 3 days after birth. We proposed a model in which walking for a purpose during pregnancy mediated the effects of symptoms of depression (measured by the 20-item Center for Epidemiologic Studies-Depression [CES-D] scale) on gestational age at birth in a sample of 1,382 African American women. ResultsUsing structural equation modeling, we found that the direct effect of CES-D scores of 23 or greater, which have been correlated with major depression diagnosis, on gestational age at birth was -4.23 (p < .001). These results indicate that symptoms of depression were associated with a decrease in gestational age at birth of 4.23 days. Walking for a purpose mediated the effect of CES-D scores of 23 or greater on gestational age at birth. ConclusionsCompared with African American women without symptoms of depression, African American women who had symptoms of depression walked less for a purpose during their pregnancy and delivered infants with lower gestational age at birth. If not medically contraindicated, clinicians should incorporate walking as part of prenatal care recommendations and reassure women about safety of walking during pregnancy.

The Impact of Adequate Prenatal Care on Urban Birth Outcomes: An Analysis in a Developing Country Context

AbstractDeficient birth outcomes entail greater mortality risks and higher probabilities of poor future health. This study examines the effect of the World Health Organization’s prenatal care recommendations for developing countries. It accounts for the endogenous nature of prenatal care decisions by using an instrumental variables approach based on the opportunity cost and accessibility of prenatal services. Using the urban sample of the Cebu Longitudinal Health and Nutrition Survey, I construct a measure of prenatal care based on the WHO recommendations. This measure involves both timing and intensity. The instrumental variable used is shown to be strong and valid. The results show that adequate care has a positive impact on birth weight and decreases the probability of poor birth outcomes. The results are robust to seasonality and time effects and are not driven by the potential influence of rainfall shocks on maternal health. I also test the effectiveness of the WHO methodology by modifying the defini...

The Impact of Adequate Prenatal Care in a Developing Country: Testing the WHO Recommendations

Deficient birth outcomes entail greater mortality risks and higher probabilities of poor future health. This study examines the effect of the World Health Organization’s prenatal care recommendations for developing countries. It accounts for the endogenous nature of prenatal care decisions by using an instrumental variables approach based on the opportunity cost and accessibility of prenatal services. Using the urban sample of the Cebu Longitudinal Health and Nutrition Survey, I construct a measure of prenatal care based on the WHO recommendations. This measure involves both timing and intensity. The instrumental variable used is shown to be strong and valid. The results show that adequate care has a positive impact on birth weight and decreases the probability of poor birth outcomes. The results are robust to seasonality and time effects and are not driven by the potential influence of rainfall shocks on maternal health. I also test the effectiveness of the WHO methodology by modifying the definition of adequate care in terms of both its timing and frequency. The results suggest that the current recommendations are appropriately defined.

Percepção das puérperas sobre a assistência prestada pela equipe de saúde no pré-natal

Trata-se de uma pesquisa qualitativa e descritiva, objetivando identificar de que modo as puérperas usuárias de um serviço público de saúde de Porto Alegre percebem a assistência prestada pela equipe de saúde no pré-natal e o que pensam sobre o acesso, o acolhimento e o atendimento recebido durante esse período. Realizamos entrevista, em setembro de 2009, com 11 puérperas, em uma maternidade de Porto Alegre-RS. Os dados coletados foram analisados e discutidos à luz das recomendações do Ministério da Saúde para o atendimento no pré-natal, e estruturados em cinco categorias: adesão ao pré-natal; acesso, acolhimento e humanização; acompanhamento do profissional de saúde no pré-natal; a visibilidade do enfermeiro no pré-natal; e finalizando o pré-natal na maternidade. Concluímos que, apesar do Programa de Humanização no Pré-Natal e Nascimento e do esforço da instituição pesquisada em adequar as políticas de saúde no seu cotidiano, ainda existem lacunas em relação à assistência humanizada e holística à gestante e puérpera

Pregnancy and Alcohol Use: Evidence and Recommendations for Prenatal Care

Pregnancy alcohol consumption has been linked to poor birth outcomes and long-term developmental problems. Despite this, a significant number of women drink during pregnancy. Although most prenatal care providers are asking women about alcohol use, validated screening tools are infrequently employed. Research has demonstrated that currently available screening methods and intervention techniques are effective in identifying and reducing pregnancy drinking. Implementing universal screening and appropriate intervention for pregnancy alcohol use should be a priority for prenatal care providers, as these efforts could substantially improve pregnancy, birth, and longer term developmental outcomes for those affected.

HIV testing during pregnancy: use of secondary data to estimate 2006 test coverage and prevalence in Brazil

This paper describes a methodological proposal based on secondary data and the main results of the HIV-Sentinel Study among childbearing women, carried out in Brazil during 2006. A probabilistic sample of childbearing women was selected in two stages. In the first stage, 150 health establishments were selected, stratified by municipality size (<50,000; 50,000-399,999; 400,000+). In the second stage, 100-120 women were selected systematically. Data collection was based on HIV-test results registered in pre-natal cards and in hospital records. The analysis focused on coverage of HIV-testing during pregnancy and HIV prevalence rate. Logistic regression models were used to test inequalities in HIV-testing coverage during pregnancy by macro-region of residence, municipality size, race, educational level and age group. The study included 16,158 women. Results were consistent with previous studies based on primary data collection. Among the women receiving pre-natal care with HIV-test results registered in their pre-natal cards, HIV prevalence was 0.41%. Coverage of HIV-testing during pregnancy was 62.3% in the country as a whole, but ranged from 40.6% in the Northeast to 85.8% in the South. Significant differences according to race, educational level and municipality size were also found. The proposed methodology is low-cost, easy to apply, and permits identification of problems in routine service provision, in addition to monitoring compliance with Ministry of Health recommendations for pre-natal care.

The production of authoritative knowledge in American prenatal care.

Using Jordan's concept of authoritative knowledge, this article describes some of the ways that the prenatal care practices of a group of U.S. women help to consolidate biomedical hegemony. We analyze the considerations that the women took into account when deciding whether or not to accept specific prenatal care recommendations as authoritative, focusing on when and how they used their own "embodied" knowledge and experience as a standard against which to assess the validity of clinical recommendations. The data provide insight into medicalization processes and the role patients themselves play in furthering biomedical hegemony.

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)

Health Beliefs and Health Care Behaviour in Pregnancy

Increasing attention is being given to the effects of maternal behavior during pregnancy on the course and outcome of the pregnancy and on the subsequent well-being of the newborn. Maternal adherence to prenatal care recommendations varies considerably and is frequently less than ideal. Many women fail to attend antenatal clinics until their pregnancies are well advanced, and a large proportion of those who attend continue to smoke and consume alcohol in spite of instructions to the contrary. The issues of fetal health and viability of the pregnancy may be considered behavioral problems on the part of the mother. Although low adherence to health care recommendations may have physiological implications, the origins of the problem are largely psychological. The present authors, in the course of studying the psychological effects of ultrasound in pregnancy, assessed health beliefs and behavior also. The results of these assessments, conducted at 16 weeks of gestation, are described herein. Real-time ultrasound examinations were performed at the first clinic visit. Women in the study were assigned at random to one of two conditions of real-time ultrasound: high feedback (N = 67), in which women were shown the monitor screen and were provided with specific verbal and visual feedback as to fetal size, shape, and movement; and low feedback (N = 62), in which the patients received a comparable examination and interview, with the sole exception that they were not able to see the monitor screen and so receive specific feedback. Women were assessed before and after the scan on a number of attitudinal and psychological measures. The biographical characteristics are presented in Table 1. Eighty per cent of the sample were still working at this time, and 24 per cent expressed the intention to resume work following delivery. All but three of the sample had been reading material related to health care during the pregnancy, and 95 per cent were taking dietary supplements (mainly iron) regularly. The majority (85 per cent) intended to attend prenatal classes, and 73 per cent expected their partners to accompany them. The women were required to report on behavioral change after the first prenatal clinic visit, and on their attitudes toward health care recommendations. Table 2 shows smoking behavior and attitudes. It can be seen that 40 of the sample admitted to smoking, with a mean number of 10.3 cigarettes per day. Among those not smoking, a near-significant association emerged with respect to quitting the practice following ultrasound.