Prenatal care in the United States

Pre-conception counseling in the United States is recommended to include:[9]

• Height and weight to calculate BMI
• Blood pressure
• Medical history
• Abdominal and pelvic examination
• Rubella screening
• Varicella screening
• Domestic violence screening
• Depression screening
• Testing for gonorrhea and chlamydia for women at high risk for STDs

It is recommended that all pregnant women receive influenza vaccination during flu season.[1] Increased infectious susceptibility in pregnancy may increase the likelihood of influenza complications such as pneumonia, particularly in the third trimester.[1] In addition, the fever, tachycardia and hypoxemia caused by influenza may be harmful to the developing fetus.[1]

Vaccination with inactivated trivalent influenza vaccine is cost saving relative to providing supportive care alone in the pregnant population,[1] but a 2009 review concluded that there was insufficient evidence to recommend routine use of it during the first trimester of pregnancy.[13] Inactivated vaccines for influenza are considered safe at any gestational age.[1] On the other hand, live attenuated influenza vaccines such as the nasal spray vaccine is not recommended in pregnancy.[1] Preservative-free vaccines are available in case of hypersensitivity to eggs or to vaccine components.[1]

Rubella is contagious viral disease, with symptoms like mild measles. Screening for rubella susceptibility by history of vaccination or by serology is recommended in the US for all women of childbearing age at their first preconception counseling visit to reduce incidence of congenital rubella syndrome (CRS).[9] Due to concerns about possible teratogenicity, use of MMR vaccine or measles vaccine is not recommended during pregnancy.[9] Susceptible pregnant women should be vaccinated as soon as possible in the postpartum period.[9]

Varicella is a herpes virus that causes chicken pox and shingles. Administration of the varicella vaccine during pregnancy is contraindicated.[9] Immunity status to varicella should be elicited during the preconception counseling visit.[9]

If an urgent need for tetanus protection occurs during pregnancy, Td vaccine should be administered.[9] If no urgent need arises and the woman has previously received tetanus vaccine, Td vaccination should be delayed until the postpartum period.[9] All postpartum women who have not received Td or Tdap vaccine in the last two years are recommended to receive Tdap prior to discharge after delivery.[9] It is recommended for pregnant women who have never received tetanus vaccine (i.e., have never received DTP, DTaP or DT as child or Td or TT as adult) to receive a series of three Td vaccinations starting during pregnancy to ensure protection against maternal and neonatal tetanus.[9] In such cases, administration of Tdap is recommended after 20 weeks' gestation,[14] and in earlier pregnancy a single dose of Tdap can be substituted for one dose of Td, and then the series completed with Td.[9]

Social networks of family, friends, and surrounding persons play a significant role in influencing an individuals' utilization of prenatal services. Networks of those underutilizing prenatal care and acting against medical recommendations tend to be larger and of higher density in comparison to women who utilize care appropriately. This suggests that populations affected by underutilizing prenatal care are larger than populations utilizing care appropriately. Social network share opinions, reach a consensus, and act to communicate and reinforce their suggestions and expectations; all of which are valued higher than that of health care professionals.[2] First-time mothers, and a supporting number of family members and friends, their social support, play a significant role in a woman's decision to seek early prenatal care and subsequent prenatal care services. The size of their "social support" encouraging prenatal care participation, increases the chance of early prenatal care utilization during the first trimester. When an increased length of time passes, women who have yet to have had an encouraging "social support" to seek early prenatal care might attend prenatal care on their own will; however, this is usually after the first trimester has passed.[4]

Attitudes influence the decisions to accept or not accept specific prenatal care recommendations based on their knowledge gained from personal experiences and outside information from social networks. One reason women do not follow doctors' advice is due to the perception that the information given is false.[17] Women often hear and experience situations in which health professions were wrong. Subsequent recommendations were then weighted to determine truth evaluability. Many women who are distrustful of biomedicine will decline certain prenatal tests, citing their own bodily knowledge as more trustworthy than their doctor's high-tech interpretations.[18] Some minority women may opt to avoid the distress and discomfort of the medical care and refuse prenatal care entirely.[19]

Having already borne healthy children increases the probability that mothers will not follow clinical recommendations, attributing positive prenatal situations to their past experiences. Personal health could be self-defined with the recognition of their own symptoms and determining if they need to seek treatment of medical professionals.[17]

Some mothers are quite uncomfortable with this lack of clearly communicated information and are consequently hesitant to pursue prenatal testing and counseling that health professionals would consider to recommend.[20]

Populations in urban inner-city settings have an increased risk of substandard prenatal care.[3] Low-socioeconomic areas experience higher rates of neonatal mortality, caused in large part by low-birth weights, than do women of higher income.[3] This statistic has the chance to decrease with an increase in the number of women entering prenatal care programs.[16] It is more likely that women of higher incomes seek prenatal care in comparison to lower income women.[21] Blacks, Hispanics, single women, women with lower levels of education (less than 12 years), teenagers under 18, women over 40, women with three or more previous births, and women with fewer socioeconomic resources have a significantly lower opportunity for satisfactory health care services.[3][22]

Studies have shown a significantly higher risk for blacks and Hispanics in receiving inadequate prenatal care.[3] African-American expectant mothers are 2.8 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care during the entirety of the pregnancy.[23] Similarly, Hispanic expectant mothers are 2.5 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care at all.[24] Latina women and African American women were likely to visit different types of health care professionals; Latina women are more likely to go see an obstetrician while African American women are more likely to see a practitioner.[25] Minorities' perspective on their prenatal care experience was partly based on the interaction with their medical provider and whether they too were of minority background and of the same gender due to cultural familiarity in how physicians interact with their patients.

A particularly consistent finding regarding the health of the Latino population is that Latina women, despite their many social and economic disadvantages (e.g., lower socioeconomic status, lower levels of education, less use of prenatal care, less access to health insurance), give birth to significantly fewer low birth weight infants and lose fewer babies to any and all causes during infancy in comparison to non-Hispanic white women.[26][27] This phenomenon is part of what is known as the “Latina paradox” or “Epidemiologic paradox”, which is a mortality advantage within the Latino population.[26] This cultural advantage begins to fade when Latina women acculturate into mainstream American culture; thus, more acculturated Latina women experience a higher infant mortality rate and give birth to more low-birth weight infants.[26][28] Exploring the factors that bring about the Latina paradox at the individual and community levels may help identify new opportunities for policy interventions to optimize prenatal outcomes in U.S born Latinas and other non-Hispanic white ethnic groups. There is no definitive explanation for what leads to a mortality advantage. Behavioral factors such as drug-use, alcohol consumption, and tobacco use may serve as a contribution to the paradox, since Latina women smoke less, consume less alcohol, and use drugs less when pregnant compared to their non-Hispanic white counterparts.[29][30] Cultural factors may be relevant to the Latina paradox since foreign-born Latina women have lower rates of low-birth weight babies than U.S. born Latina women and non-Hispanic white women. Alternatively, community factors such as the acculturation of the community and the values of the community may also contribute to the paradox.

Unintended pregnancy precludes pre-conception counseling, and pre-conception care, and delays initiation of prenatal care.[31] In unintended pregnancies, prenatal care is initiate later, and is less adequate.[32] This adversely affects health of woman and of child, and the woman is less prepared for parenthood.[32] Delay from unintended pregnancy is in addition to that from other risk factors for delay.[32]

The United States rate of unintended pregnancies is higher than the world average, and much higher than that in other industrialized nations.[33] Almost half (49%) of U.S. pregnancies are unintended, more than 3 million unintended pregnancies per year.[34][35] The rate of unintended pregnancy is even higher among the poor. In 1990 about 44% of births were unintended at time of conception; among poor women almost 60% of births were due to unintended pregnancies.[36]

Of those women who become pregnant every year in the United States 13 percent are uninsured, resulting in severely limited access to prenatal care. According to Children's Defense Fund's website, "Almost one in every four pregnant Black women and more than one in three pregnant Latina women is uninsured, compared with one in nearly seven pregnant White women. Without coverage, Black and Latina mothers are less likely to access or afford prenatal care."[37] Currently, pregnancy is considered a "pre-existing condition," making it much harder for uninsured pregnant women to actually be able to afford private health insurance.[38] In 1990, 1995, and 1998, the expansion of MediCal increased the use of prenatal care and reduced ethnic differences in those who utilized health services.[22]

Data has shown that those with access to Medicaid account for 58 percent of women who underutilize prenatal care; those with access to another type of insurance coverage account for 11 percent of women who underutilize prenatal care.[2]

Women with fewer than 12 years of education are at high risk of underutilizing or lacking access to adequate prenatal care services.[3] Oftentimes, Black and Hispanic pregnant women have fewer years of formal education, which sparks a domino effect of consequences related to prenatal care. A lack of formal education results in less knowledge about pregnancy appropriate prenatal healthcare as a whole, fewer job opportunities, and a lower level of income throughout their adult life.[39]

Without proper prenatal care services, there are an increase in complication rates [40] such as:

• Intrauterine growth restriction: the poor growth of babies while in the mother's womb
• Preeclampsia: hypertension occurs during pregnancy
• Preterm premature rupture of membranes: the rupture of the amnionic sac and chorion more than an hour before the start of labor
• Gestational diabetes: women who have not previously suffered diabete prior to pregnancy exhibit high blood glucose levels during pregnancy due to the mother's lack of ability to secrete insulin.
• Placenta previa: the placenta is attached to the uterine wall close to or covering the cervix
• Preterm birth: babies are born less than 37 weeks of their full gestational age. Premature newborns can suffer from immature lungs that is associated with respiratory complications.[41]

Every year in the United States 875,000 women experience one or more pregnancy complications and 467,201 babies are born prematurely.[42]

Every year in the United States, 27,864 new borns are born with low birth weight.[42] New borns of mothers who do not utilize prenatal care are three times more likely to have a low birth weight and five times more likely to die in comparison to new borns whose mothers regularly attended prenatal care check-ups.[1] Sesia et al. found a positive association with the number of prenatal care visits and birth weight.[3] Low birth weight are associated with prematurity and contributes to rates of infant mortality.

Every year in the United States, 154,051 children are born with birth defects.[42] Congenital malformations may be caused by:

• Genetic disorders
• Intrauterine environment
• Errors of morphogenesis, the biological process that causes an organism to develop its shape.
• Chromosomal abnormality

Some commonly known congenital malformations are:

• Cleft palate: a fissure or opening in the lip
• Heart defects
• Down syndrome: the presence of all or a part of an extra 21st chromosome.[43]

Prenatal care deficits and postnatal environments work together in a complex manner to influence the outcomes of congenital disorders.[44]

In 2000, the United States ranked 27th among industrialized countries for their relatively high infant mortality rate.[45] Data from 2003 shows that the infant mortality rate was 6.9 deaths per 1,000 per live births.[45] Every year in the United States, 27,864 infants die before their first birthday.[42] The United States' mortality rate is one of the highest amongst other developed countries. It is associated with maternal health, socioeconomic conditions, and public health practices.[46] Inadequate use of prenatal care is a strong predictor of low infant birth weight, prematurity, and infant mortality.[22]

Preventing unintended pregnancies would have many desirable health, social and financial results, including increasing the proportion of pregnancies with adequate and timely access to prenatal care. Programs to help reduce unintended pregnancy include increased education about and access to contraceptives and improved sex education.

For many patients, it is difficult to develop a long-standing and trusting relationship with healthcare providers.[48] Regardless of socioeconomic background, women will incorporate beneficial life style changes that are easily incorporated into their daily lives. Data from Browner et al. found that pregnant women do not regard prenatal recommendations to be authoritative simply because they were issued by clinical professionals, with that they tend to follow recommendations by their own discretion. Using prenatal diagnostic tests may enforce the importance of following doctor's orders.[17] Medical staff should aim to establish effective lines of communication with health care providers to ensure an increase awareness of women's health while establishing trust with their patients.[3] If patients cannot be matched with healthcare providers culturally, then they should at least be able to visit a physician who is trained specifically to deal with cultural differences. This awareness and sensitivity can come in many forms, such as a familiarity with a foreign language, an understanding of how a specific ethnicity views mothers, or knowing how family networks play into the mothers’ decision-making process. All of these options have the potential to improve doctor-patient relationships, and the establishment of such relationships can be implemented in medical training in the US both in medical school settings and on-site training programs.[49]

It has been suggested that physicians and other health care providers screen their patients for both abuse and sexually transmitted diseases to ensure their overall well being.[50] They should also aid them in getting the proper treatment, health, social and legal services if a problem exists.[50]

The lack of adequate health insurance, specifically health insurance in the United States, can contribute to the limitations and underutilization experienced by women.[2] Hessolhas two studies demonstrating that insurance status is a strong determinant of the utilization of prenatal care; as eligibility of health insurance increased, the use of prenatal care increased and ethnic differences decreased.[22] Although, while private health insurance is one method to which women can access or afford prenatal care, private health insurance has not always proven to necessarily be helpful or reassuring.[17]

Sesia et al. found no significant differences suggesting that a mandatory managed care program for prenatal care improved nor impeded access to prenatal care services.[3] A study done on women utilizing prenatal care services found that resources provided by an HMO program, such as prenatal education classes, recommendations for diet, exercise, weight gain, and rest, pregnancy books, and magazines subscriptions, were not viewed by women as being helpful.[17]

Community outreach programs would train members of the minority population in basic health education; then these community health workers would help to facilitate connections between expectant mothers and local healthcare establishments. The community health workers could even continue their relationship throughout the duration of the pregnancy, serving as a patient liaison during the various tests, appointments, and conversations.[2][51] Communities of low-income should employ community residents to encourage and support the utilization of health care services.[16]

Those with outreach contact were more likely to serve disadvantaged populations such as those reported with obstetric risks, younger than 19 years old, and less likely to have a significant partner.[16] Targeting this population through community outreach programs that take on community projects can have a positive effect of rates of women accessing and utilizing prenatal care services available.

Suggestions of supporting teen health centers have been made to provide health care services. Resources from this study strongly suggests that prenatal care delivered in a community-base setting is a more efficient and cheaper method for providing positive health outcomes; however, the missions of community-based care program are different. In relation to teenagers or adolescent medicine, a focused community program may lead to an increase in contraceptive use and a decrease in the rate of subsequent pregnancies.[52]