Current Trends State-Specific Trends Among Women Who Did Not Receive Prenatal Care -- United States, 1980-1992

Lack of prenatal care is strongly associated with an increased risk for low birthweight ( less than 2500 g {less than 5 lbs 8 oz} at birth) infants, preterm delivery, and maternal and infant mortality (1). From 1980 through 1992, the nationally aggregated percentage of pregnant women who did not receive prenatal care increased by 31% -- from 1.3% to 1.7% (2,3). Because nationally aggregated data can obscure variations among states, CDC analyzed state-specific data derived from birth certificates for 1980-1992 to examine trends among women who did not receive prenatal care. This report summarizes the findings of the analysis.

Prenatal-care data were ascertained from the section on the birth certificate indicating the month of pregnancy in which prenatal care was initiated. State-specific percentages for each year from 1980 through 1992 were ordered from lowest to highest to determine the 25th, 50th (i.e., median), and 75th percentiles and maximum value for each year. In addition, state-specific percentages for women who did not receive prenatal care were compared for 1980-1981 and 1991-1992 using the total number of births to women who did not receive prenatal care and the total number of births. Absolute change was calculated by comparing the percentages for 1980-1981 with those for 1991-1992.

From 1980 to 1989, the median state-specific percentage of births to women who did not receive prenatal care increased from 0.8% to 1.3% Figure_1. Although patterns for the 25th and 75th percentiles were similar, the maximum value increased substantially -- from 3.7% in 1980 to 7.5% in 1989; in 1992, the percentage declined to 4.8%. Percentages were consistently high in the District of Columbia, Florida, New Mexico, New York, and Texas.

For 1980-1981, the percentage of women who did not receive prenatal care ranged from 0.14% (Vermont) to 3.67% (New York) Table_1; for 1991-1992, the percentages ranged from 0.32% (Utah) to 5.63% (District of Columbia). When compared with 1980-1981, during 1991-1992 the percentage of women who did not receive prenatal care declined in eight states (Florida, Kentucky, New Jersey, New York, Oklahoma, Rhode Island, South Dakota, and Utah) and increased in 42 states and the District of Columbia; in nine states, the increase was greater than 100% (Delaware, Illinois, Indiana, Louisiana, Michigan, Ohio, Pennsylvania, Vermont, and Wisconsin). Reported by: Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Health and Utilization Analysis, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: Federal and state initiatives during the mid-1980s aimed to increase access to prenatal care by expanding Medicaid eligibility and increasing funding for maternal and child health block grants and other state-funded programs (4,5). The decrease in the percentage of births to women who did not receive prenatal care during 1991-1992 is the most substantial decrease recorded since 1969 (the first year data about prenatal-care initiation were reported). Despite these improvements, approximately 69,000 women did not receive prenatal care in 1992.

Health agencies commonly use aggregated data to describe national patterns in prenatal care in the United States. However, the findings in this and other reports indicate the importance of using state-specific data to fully elucidate and better understand long-term trends (6). In particular, these findings documented substantial variation among states for the percentage of women who did not receive prenatal care. For example, the comparison of data for 1980-1981 with 1991-1992 demonstrated slight decreases in the percentage of women who did not receive prenatal care in eight states and substantial increases in nine others.

The findings in this report are subject to at least two limitations. First, the overall increase in the percentage of women who did not receive prenatal care may have been related to improved case ascertainment. From 1980 to 1992, the percentage of women for whom initiation of prenatal care was unknown decreased from 2.8% in 1980 to 2.2% in 1992. However, the increase in the percentage of women who did not receive prenatal care may have been related to the decrease in the percentage of women who initiated prenatal care during the second trimester (from 18.1% in 1980 to 16.7% in 1992). The percentages of women who initiated prenatal care during the first or third trimester remained unchanged (74% and 4%, respectively). Second, estimates of the prevalence of nonreceipt of prenatal care may be inaccurate because a standard method of measuring initiation of prenatal care is not available. Although maternal postpartum interview data (7) and birth certificate data identify similar percentages of women who do not receive prenatal care, these sources may not identify the same women. For example, in a national sample of women who gave birth in 1988, among those who were identified either by the birth certificate or maternal interview as not receiving prenatal care, only 33% were identified by both sources (7).

Because the importance of prenatal care is widely accepted and efforts are made to provide such care to all women, nonreceipt of prenatal care should be considered a sentinel health event. A sample of these episodes should be investigated to identify and implement interventions. In particular, public health workers need to determine the reasons for nonreceipt of prenatal care (e.g., choosing not to obtain care, inability to pay for care, or lack of providers or transportation), and state health departments should consider the financial, programmatic, and social factors that are associated with nonreceipt of prenatal care.

References

1. Office of Technology Assessment, US Congress. Healthy children: investing in the future. Washington, DC: US Congress, Office of Technology Assessment, 1988.

2. NCHS. Vital statistics of the United States, 1980. Vol I, natality. Washington, DC: US Department of Health and Human Services, Public Health Service, 1984; DHHS publication no. (PHS)85-1100.

3. Ventura SJ, Martin JA, Taffel SM, et al. Advance report of final natality statistics, 1992. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Monthly vital statistics report; vol 43, no. 5, suppl).

4. Singh S, Forrest JD, Torres A. Prenatal care in the United States: a state and county inventory. Vols 1 and 2. New York: Alan Guttmacher Institute, 1989.

5. Committee to Study Outreach for Prenatal Care, National Institute of Medicine. Prenatal care: reaching mothers, reaching infants. Washington, DC: National Academy Press, 1988.

6. Ingram DD, Makuc D, Kleinman JC. National and state trends in use of prenatal care, 1970-83. Am J Public Health 1986;76:415-23.

7. Schoendorf KC, Parker JD, Batkhan LZ, Kiely JL. Comparability of the birth certificate and 1988 Maternal and Infant Health Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1993; DHHS publication no. (PHS)93-1390. (Vital and health statistics; series 2, no. 116).

+------------------------------------------------------------------- --------+ |             | | Errata: Vol. 43, No. 50 | | ======================= | | SOURCE: MMWR 44(05) DATE: Feb 10, 1995 | |             | | In the article "State-Specific Trends Among Women Who Did Not | | Receive Prenatal Care -- United States, 1980-1992," on page 939, in | | the second sentence of the third paragraph, the maximum value in | | 1992 declined to 5.7%, rather than 4.8%. The fourth paragraph | | should read: "For 1980-1981, the percentage of women who did not | | receive prenatal care ranged from 0.18% (Vermont) to 3.64% (New | | York) Table_1E; for 1991-1992, the percentages ranged from 0.30% | | (Rhode Island) to 6.07% (District of Columbia). When compared with | | 1980-1981, during 1991-1992 the percentage of women who did not | | receive prenatal care declined in nine states (Florida, Kentucky, | | Minnesota, New Jersey, New York, Oklahoma, Rhode Island, South | | Dakota, and Utah) and increased in 41 states and the District of | | Columbia; in eight states (Delaware, Illinois, Indiana, Louisiana, | | Michigan, Pennsylvania, Vermont, and Wisconsin) and the District of | | Columbia, the increase was greater than 100%." | | On page 940, the fourth sentence in the second paragraph | | should read, "For example, the comparison of data for 1980-1981 | | with 1991-1992 demonstrated slight decreases in the percentage of | | women who did not receive prenatal care in nine states and | | substantial increases in eight states and the District of | | Columbia." On page 941, the state-specific percentages were | | incorrect for several states. The following table contains the | | corrected percentages and replaces Table_1E. | +------------------------------------------------------------------- --------+

TABLE 1. Percentages of women who did not receive prenatal care, by
state -- United States, 1980-1981 and 1991-1992
=====================================================================================
                                             Absolute change *      % Change *
                                             from 1980-1981       from 1980-1981
State              1980-1981     1991-1992    to 1991-1992          to 1991-1992
-------------------------------------------------------------------------------------
Alabama               1.36         1.38            0.03                1.86
Alaska                0.68         0.80            0.12               17.60
Arizona               1.93         2.24            0.30               15.74
Arkansas              1.45         1.79            0.34               23.52
California            0.93         1.33            0.40               43.61
Colorado              0.79         1.03            0.25               31.53
Connecticut           0.47         0.50            0.03                5.47
Delaware              0.59         1.71            1.12              189.85
District of Columbia  3.10         5.63            2.53               81.75
Florida               2.05         1.85           -0.20               -9.90
Georgia               1.34         2.13            0.79               58.84
Hawaii                0.54         0.84            0.30               55.47
Idaho                 0.81         1.02            0.21               25.80
Illinois              1.01         2.04            1.03              102.48
Indiana               0.92         2.21            1.28              138.82
Iowa                  0.36         0.53            0.17               47.52
Kansas                0.51         0.76            0.25               48.00
Kentucky              1.94         1.55           -0.39               -19.97
Louisiana             1.21         2.53            1.33              109.92
Maine                 0.82         1.06            0.24               29.69
Maryland              0.85         1.29            0.44               51.29
Massachusetts         0.39         0.50            0.11               28.72
Michigan              0.66         1.50            0.84              128.02
Mississippi           0.42         0.49            0.07               17.07
Minnesota             0.83         1.26            0.43               51.78
Missouri              0.92         1.72            0.79               85.82
Montana               0.74         0.87            0.13               18.18
Nebraska              0.41         0.60            0.19               45.33
Nevada                1.61         2.87            1.25               77.52
New Hampshire         0.42         0.79            0.37               87.83
New Jersey            1.63         1.25           -0.38              -23.38
New Mexico            1.73         2.88            1.15               66.68
New York              3.67         3.13           -0.54              -14.69
North Carolina        0.90         1.69            0.80               88.60
North Dakota          0.50         0.64            0.13               26.92
Ohio                  0.69         1.45            0.76              109.77
Oklahoma              1.88         1.35           -0.54              -28.54
Oregon                0.69         0.97            0.28               40.97
Pennsylvania          0.68         1.80            1.12              165.33
Rhode Island          0.47         0.40           -0.07              -14.27
South Carolina        1.15         2.04            0.89               76.79
South Dakota          2.43         1.16           -1.28              -52.43
Tennessee             1.30         1.53            0.24               18.14
Texas                 2.71         3.82            1.11               41.09
Utah                  0.40         0.32           -0.09              -21.68
Vermont               0.14         0.38            0.24              173.66
Virginia              0.76         1.45            0.69               90.52
Washington            0.58         0.83            0.25               42.87
West Virginia         0.93         1.14            0.21               22.78
Wisconsin             0.37         0.76            0.39              103.86
Wyoming               0.79         0.88            0.09               11.71
-------------------------------------------------------------------------------------
* Manual calculations of the absolute and percentage changes may not be exact
  because of rounding.
=====================================================================================

TABLE 1. Percentages of women who did not receive prenatal care, by state -- United
States, 1980-1981 and 1991-1992 and 1991-1992
====================================================================================
                                                 Absolute change *    % Change*
                                                 from 1980-1981     from 1980-1981
State                  1980-1981   1991-1992      to 1991-1992       to 1991-1992
------------------------------------------------------------------------------------
Alabama                   1.36         1.38            0.03              1.88
Alaska                    0.68         0.80            0.12             17.60
Arizona                   1.93         2.24            0.30             15.74
Arkansas                  1.45         1.79            0.34             23.52
California                0.93         1.58            0.65             70.29
Colorado                  0.79         1.03            0.25             31.53
Connecticut               0.47         0.50            0.03              5.47
Delaware                  0.59         1.73            1.14            192.53
District of Columbia      1.54         6.07            4.53            295.32
Florida                   2.05         1.85           -0.20             -9.90
Georgia                   1.34         2.13            0.79             58.84
Hawaii                    0.54         0.84            0.30             55.47
Idaho                     0.81         1.02            0.21             25.80
Illinois                  1.01         2.04            1.03            102.48
Indiana                   0.92         2.21            1.28            138.82
Iowa                      0.36         0.53            0.17             47.52
Kansas                    0.51         0.76            0.25             48.00
Kentucky                  1.94         1.55           -0.39            -20.07
Louisiana                 1.21         2.53            1.33            109.92
Maine                     0.82         1.06            0.24             29.69
Maryland                  0.85         1.29            0.44             51.29
Massachusetts             0.39         0.50            0.11             28.72
Michigan                  0.66         1.50            0.84            128.02
Minnesota                 0.61         0.50           -0.12            -19.09
Mississippi               0.85         1.36            0.51             60.26
Missouri                  0.99         1.64            0.65             66.41
Montana                   0.72         0.77            0.05              6.54
Nebraska                  0.40         0.63            0.23             58.46
Nevada                    1.44         2.78            1.35             93.76
New Hampshire             0.39         0.72            0.33             84.55
New Jersey                1.48         1.33           -0.16            -10.51
New Mexico                1.84         2.68            0.84             45.48
New York                  3.64         2.69           -0.95            -26.11
North Carolina            0.92         1.47            0.55             60.41
North Dakota              0.56         0.58            0.02              3.32
Ohio                      0.79         1.50            0.71             89.64
Oklahoma                  1.95         1.16           -0.78            -40.28
Oregon                    0.78         0.85            0.06              8.25
Pennsylvania              0.73         1.74            1.01            137.07
Rhode Island              0.45         0.30           -0.15            -33.79
South Carolina            1.19         1.88            0.68             57.45
South Dakota              2.00         1.25           -0.75            -37.38
Tennessee                 1.33         1.41            0.08              6.35
Texas                     2.80         4.10            1.31             46.85
Utah                      0.42         0.32           -0.10            -24.31
Vermont                   0.18         0.38            0.21            116.11
Virginia                  0.75         1.35            0.60             80.57
Washington                0.55         0.65            0.09             16.68
West Virginia             0.92         0.92            0.00              0.41
Wisconsin                 0.38         0.77            0.40            105.45
Wyoming                   0.81         0.93            0.12             15.04
------------------------------------------------------------------------------------
* Manual calculations of the absolute and percentage changes may not be exact
  because of rounding.
====================================================================================

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