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Show Barriers to Adequate Prenatal Care in Utah Kirsten Davis, B.S.; Laurie Baksh, M.P.H.; Lois Bloebaum, B.S.N.; Nan Streeter, M.S., R.N.; Bob Rolfs, M.D. M.P.H. It is widely accepted that inadequate prenatal care (PNC) is a risk factor for low birth weight infants and other adverse pregnancy outcomes. The UnitedHealth Group State Health Ranking report of 2000 ranked Utah 49th in the nation for adequacy of PNC. For this article, PRAMS and birth certificate data from 1999 were analyzed to identify barriers to early and continuous PNC. In Utah, only 63% of women received adequate PNC. Of the women with inadequate PNC, 12.5% received inadequate care due to late entry and 24.6% received inadequate PNC due to an insufficient number of visits despite appropriate entry time. There is definite need for improvement in the entry and adequacy of prenatal care in Utah. Inadequate prenatal care (PNC) is a risk factor for low birth weight babies and other adverse pregnancy outcomes. Women who receive adequate PNC have a reduced risk for low birth weight infants, and maternal and infant morbidity and mortality, by identifying high-risk pregnancies early in gestation and providing risk reduction interventions. According to the U.S. Department of Health and Human Services, risk assessment at the first prenatal visit can identify as many as 80% of women at high risk of having a low birth weight infant (National Commission to Prevent Infant Mortality, 1988). This risk reduction is particularly beneficial to medically and socio-economically high-risk women (Committee to Study the Prevention of Low Birthweight, 1985). Comprehensive PNC includes maternal risk assessment, risk reduction or treatment for medical conditions, and education. Prenatal care also provides an opportunity to address behavioral risks that contribute to adverse pregnancy outcomes, such as smoking, alcohol use, and poor nutrition (Division of Community and Family Health Services, 2001). Research has shown that the barriers to receiving PNC are diverse and range from demographic to psychosocial. Studies have cited unwanted or unplanned pregnancies, no regular provider of medical care before pregnancy, lower education levels, multi-parity, lack of transportation, lack of childcare, inability to obtain an appointment, less than 20 years of age (Braveman, Marchi, Egerter, Pearl, & Neuhaus, 2000), having Medicaid or no insurance, being unemployed, being unmarried (Pagnini & Reichman, 2000), fear of disclosure of the pregnancy (Baker, 1996), the woman's perception of the importance of PNC (Roberts et al., 1998), and timing of recognition of the pregnancy as barriers to receiving early and adequate PNC. Healthy People 2010 (HP2010) is a national health promotion and disease prevention agenda developed by the U.S. Department of Health and Human Services. Its goals serve to improve the health of all U.S. inhabitants by the year 2010. There are two HP2010 goals for PNC; for 90% of pregnant women to begin PNC in the first trimester of pregnancy, and for 90% of pregnant women to obtain early and adequate PNC. The U.S. baseline measures for these outcomes in 1998 were 83% for first trimester entry and 74% for early and adequate PNC (U.S. Department of Health and Human Services, 2000). In 1998 the rate of first trimester entry into PNC in Utah was 80% and the rate for early and adequate PNC was 63.5%. The UnitedHealth Group State Health Ranking Report of 2000 ranked Utah 49th in the nation for adequacy of PNC (UnitedHealth Group, 2000). Ranks were based on National Center for Health Statistics 1998 data. Adequacy was determined using the modified Institute of Medicine (Kessner) index (Institute of Medicine, 1973), which defines adequate care as having the first PNC visit occur in the first trimester and having a cumulative number of PNC visits during the remainder of the pregnancy. For example, a women with a pregnancy of 36 weeks or greater should be seen at least 9 times in order to be classified as having received adequate PNC. METHODOLOGY Data in this report were provided by the Utah Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is an ongoing, population-based risk factor surveillance system designed to identify and monitor selected maternal experiences that occur before and during pregnancy and experiences of the child's early infancy. Each month, a sample of approximately 200 women two to four months postpartum is selected. The survey is administered both in English and Spanish. The sample is stratified based upon race and birth weight so that inferences and comparisons about these groups can be made. The results are weighted for sample design and non-response. Women are asked questions about prenatal care, breastfeeding, smoking and alcohol use, physical abuse and early infant care. PRAMS is intended to help answer questions that birth certificate data alone cannot answer. Data will be used to provide important information that can guide policy and other efforts to improve care and outcomes for pregnant women and infants in Utah. The PRAMS data reported here represents all live births to Utah residents in 1999. A total of 2140 mothers were selected to participate in the project and 1540 mothers responded for a response rate of 72%. Survey results are weighted for non-response so that analyses can be generalized to the entire population of Utah women delivering live births. For this report, adequacy of PNC was determined using the Adequacy of Prenatal Care Utilization (APNCU) Index developed by Milton Kotelchuck (Kotelchuck, 1994). THE APNCU Index characterizes PNC utilization based on two factors: the timing of initiation of PNC and the frequency of PNC visits once care has begun. The APNCU Index differs from the Kessner Index in that a woman can have second trimester entry into PNC, but still achieve adequate PNC if the number of visits is Utah's Health: An Annual Review Volume LX 5 |
