Prenatal care

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A doctor performs a prenatal exam.

Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant problems. Animal studies indicate that mothers' (and possibly fathers') diet, vitamin intake, and glucose levels prior to ovulation and conception have long-term effects on fetal growth and adolescent and adult disease.[1]

While availability of prenatal care has considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in many developed as well as developing nations.

One prenatal practice is for the expecting mother to consume vitamins with at least 400 mcg of folic acid to help prevent neural tube defects.

Prenatal care generally consists of:

  • monthly visits during the first two trimesters (from week 1–28)
  • biweekly from 28 to week 36 of pregnancy
  • weekly after week 36 (delivery at week 38–40)
  • Assessment of parental needs and family dynamic

Contents

[edit] Physical examination

Physical examinations generally consist of:

[edit] Ultrasound

Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy.

Among other things, ultrasounds are used to:

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:

  • 7 weeks — confirm pregnancy, ensure that it's neither molar or ectopic, determine due date
  • 13–14 weeks (some areas) — evaluate the possibility of Down Syndrome
  • 18–20 weeks — see the expanded list above
  • 34 weeks (some areas) — evaluate size, verify placental position

[edit] Prenatal Care and Race in the USA

Many health professionals consider prenatal care a nearly essential practice for pregnant women; however, there are wide gaps in the American population regarding who has access to these services and who actually utilizes these services. For example, 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.[2] 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.[3] The following factors impact a woman’s likelihood of acquiring prenatal care:

  • Health Insurance: 13% of women who become pregnant every year in the United States 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.”[4] 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.[5]
  • Formal Education: Oftentimes, Black and Hispanic pregnant women have fewer years of formal education, which sparks a large 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.[6]
  • Trust & Comfort with Healthcare Industry: Many minority women have limited experience with the healthcare industry on a whole, as compared to their Caucasian counterparts. Consequently, there is a lower level of trust with physicians, nurses, and the entire care regimen. 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.[7] Even worse, some minority women may opt to avoid the distress and discomfort of the medical industry and refuse prenatal care entirely.[8]
  • Understanding of Prenatal Testing: Many ethnic/racial minority mothers are referred to genetic counseling and prenatal testing centers after being declared “at-risk” for birth defects after initial screenings. However, few testing centers effectively communicate what occurs during the various tests, what the test is looking for, or what the various results could mean for the remainder of the pregnancy. Therefore, 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 recommendable.[9]

[edit] Consequences of Minorities’ Limited Access to Prenatal Care

Without timely, thorough, and appropriate prenatal care, the racial minorities of the United States continue to face severe consequences for the birth outcome of both infant and mother.

  • Low Birth Weight: Black infants are almost twice as likely to be born at a low birth weight as White babies.[11] This birth complication is ranked as the most prevalent cause of death among African American infants, claiming 1780 lives in 2005.[12]
  • Congenital Malformations: Any genetic factor or prenatal event that adversely affects the development of the fetus in utero can result in a congenital malformation. Some commonly known congenital malformations are cleft palate, heart defects, and Down syndrome.[13] As of 2005, congenital malformations are the leading cause of death among Hispanic infants, claiming 1373 lives.[14]
  • Infant Mortality: In the United States, the non-Hispanic white population experiences an infant mortality rate of 5.8 deaths per every 1000 live births. The African-American population’s infant mortality rate is 2.3 times greater (13.6 deaths per 1000 live births).[15]
  • Impact of Prenatal Care on Birth Outcomes: When women utilize prenatal care appropriately, many of them increase their chances of having a successful birth outcome. For example, prenatal care includes discussions with physicians about what lifestyle changes should be made during pregnancy (such as tobacco or alcohol cessation); if these changes do not occur, the pregnancy is more likely to be problematic or result in an infant with a defect or prone to early mortality.[16] Additionally, doctors can provide prescriptions for specific prenatal vitamins and supplements to ensure a healthy mother and infant.[17] Finally, specific prenatal tests screen for genetic abnormalities, and expectant mothers can learn if their fetuses have any significant defects prior to delivery; in these situations, physicians and genetic counselors can help advise mothers about their options for continuing the pregnancy.[18] While some poor birth outcomes cannot be entirely avoided through prenatal care, the pregnant woman can receive important information, advice, and guidance about her own individual situation, rather than being surprised in the delivery room with some unexpected news.
  • Pregnancy and Exercise: Updated recommendations by the American College of Sports Medicine suggest at least 2-1/2 hours of moderate-intensity aerobic activity spread throughout the week for pregnant and postpartum women. Women who regularly engage in high-intensity or higher amounts of activity may continue under the counsel of their health care professional provided their condition remains unchanged. For more information on the exercise recommendations and the survey of health professionals, go to http://www.acsm.org.[19]

[edit] Prenatal Care and the Latina Paradox

Prenatal care is a vital reproductive health service, which is provided by a health care professional, that helps ensure women have a healthy pregnancy. [20] Evidence demonstrates that women who regularly see their health care provider during their pregnancy have healthier babies, are less likely to deliver prematurely, and are less likely to have serious pregnancy complications. [21] Nevertheless, this evidence does not appear to be true when referring to pregnant Latina women. A particularly fascinating and 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. [22] [23] This phenomenon is part of what is known as the “Latina paradox” or “Epidemiologic paradox”, which is a mortality advantage within the Latino population. [24] 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.[25] [26] 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.[27] [28] 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. [29] Alternatively, community factors such as the acculturation of the community and the values of the community may also contribute to the paradox. Communities that retain or promote traditional Latino values (e.g., familial integrity, high regard for parental roles) could exert a favorable influence on pregnancy outcomes among pregnant women within the community, even when confronted with adverse socioeconomic factors.[30] Social support networks that consist of family, friends, and neighbors may also provide informal prenatal care and postpartum support to pregnant Latina women. The tradition of helping other women, especially pregnant women, in the community is very strong in Latin American countries. According to a study conducted by McGlade et al. (2004) the exact mechanisms through which an individual’s social support system contribute to positive birth outcomes is not entirely clear. This support can possibly mitigate the unpleasant effects of poverty through the pooling of resources. Social support systems may possess a stress-buffering effect that improves the physiological and psychological environment in which pregnancies occur.

It has been continually shown that the socio-cultural protective factors responsible for positive birth outcomes among immigrant Latina women tend to erode as subsequent generations acculturate into mainstream American culture. For example, in a study conducted by Collins et al. (1994) that looked at over 22,000 Mexican American births in the state of Illinois showed that U.S. born Mexican-American mothers had worse birth outcomes than immigrant women from Mexico. They also found that low-income Mexican born mothers had low-birth weight infant rates of 3%, while low-income U.S. born Mexican American mothers had low-birth weight infants of 14%.[31] These findings support the hypothesis that cultural “protective” factors act as a substitute, in some part, for formal prenatal care.

The loss of this “protection” in birth outcomes in U.S. born Latina women is caused in part by the acculturation process into the norms of mainstream American culture and society. In an analysis of Scribner’s et al. (1989) study on the effects of acculturation on low-birth weight infants among Latina women, the data demonstrated that higher levels of acculturation among Mexican-American women, as measured by language preference, nativity status, and ethnic identification, were associated with higher rates of low-birth weight infants.[32] The data was reanalyzed; diet and smoking were controlled for, but even then, acculturation was still shown to be a significant and pivotal indicator of low-birth weight—signifying that there are other protective factors, health behaviors, or social support systems that contribute to the Latina paradox.

In order to maintain the positive birth outcomes experienced by foreign-born Latina women, one should endorse the advantages of the health-promoting/health-protecting cultural and social environment within Latino communities, namely, the informal systems of prenatal care. This is not to discount the significance of clinical (i.e., formal) prenatal care. The benefits of prenatal care services are incontestable and apply to non-Hispanic white groups and U.S. born Latina groups. There should be some overlap between formal prenatal care services and informal prenatal care services where both systems can complement one another. There can be an expansion of the roles of individuals who participate to some degree in both the formal and informal systems of prenatal care. Some of these individuals include midwives, community health workers, and caregivers who offer support during labor and the post-partum interlude.[33] These individuals are usually members of the community who have had formal and informal training in child and maternal health that can assist in serving several integrating functions. Foremost, they can reach out to pregnant women to ensure that they are aware and can access formal prenatal care services. Secondly, they can represent older immigrant women from the community, whose knowledge and experience are fundamental to cultivating the benefits that appear to be lost with acculturation. Representing these older immigrant women validates their beliefs and practices, which may be looked down upon by more acculturated women, and it empowers these women to act as community leaders; thus, possibly helping to preserve the traditional Latino cultural and social context, within the community, that appears to have advantageous health effects. Third, these older immigrant women can offer advice on the types of traditional foods pregnant women should consume (e.g., beans, herbs, cactus). Nevertheless, these female lay practitioners can organize community members to provide the type of social support system for pregnant women that exists in Latin American countries but that often disappear and disintegrate once in the United States.

Research and data describing birth and pregnancy outcomes of Latina women call into question our conventional ideals about prenatal care services in the United States. The data demonstrates that foreign-born Latina women are committing themselves to something other than attending their regular prenatal medical care checkups, in order to ensure good maternal health, healthy infants, and safe deliveries. This Latina/Epidemiologic paradox can be partially enlightened by the functioning of informal systems of prenatal care that bestow socially and culturally mediated benefits; nevertheless, these advantages begin to disintegrate as Latinas begin to acculturate into American mainstream culture. Sustaining the activities and purpose of these informal systems of prenatal care and integrating them with formal prenatal care systems through the expanded use of lay health practitioners of the community has the capacity to improve access to prenatal care and birth outcomes at a relatively low cost. There needs to be smarter decisions made regarding the type of preventive care that in reality generates and brings about a difference in the lives of pregnant women and babies. In the current period and state of healthcare reform, the need for more research seems paramount to find answers to make sound policy.

[edit] Prenatal Care Improvements for Minorities

Although minorities continue to face decreased access to high-quality prenatal care, there are specific improvements the biomedical field can make to fix this disparity.

  • Connect physicians and patients on a cultural level: For many minority patients, it is difficult to develop a long-standing and trusting relationship with healthcare providers of different cultural backgrounds, as each culture has its own priorities, values, and goals.[34] In traditionally underserved communities with sizeable minority populations, healthcare providers should strive to offer physicians and nurses who match the racial background of the patients they are working to serve.
  • Improve all providers’ cultural awareness and sensitivity: 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 this sort of education can be implemented in medical training programs both in medical school settings and on-site training programs.[35]
  • Community Outreach Programs: Because hospitals and doctors’ offices are unfamiliar and unwelcoming places for some individuals, the healthcare industry should establish a multifaceted community outreach program in large cities. These 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.[36]

[edit] References

  1. ^ Rutecki GW. (2010). "Pre-prenatal care: a primary care primer on the future". Consultant 50 (3): 129. http://www.consultantlive.com/display/article/10162/1532211. 
  2. ^ “Health Status of African American Women,” The Office of Minority Health, U.S. Department of Health & Human Services, http://minorityhealth.hhs.gov/templates/content.aspx?ID=3723.
  3. ^ “Hispanic/Latino Profile,” The Office of Minority Health, U.S. Department of Health & Human Services, http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=31.
  4. ^ “Racial & Ethnic Disparities,” Children’s Defense Fund, http://www.childrensdefense.org/helping-americas-children/childrens-health/racial-ethnic-disparities.html#prenatal.
  5. ^ “Health Insurance for Pregnant Women,” American Pregnancy Association, http://www.americanpregnancy.org/planningandpreparing/affordablehealthcare.html.
  6. ^ Andrew J. Healy et al., “Early Access to Prenatal Care: Implications for Racial Disparity in Perinatal Mortality,” Obstetrics & Gynecology, Vol. 107, No. 3, 2006: 626.
  7. ^ Susan Markens, Carole H. Browner, and H. Mabel Preloran, “Interrogating the dynamics between power, knowledge, and pregnant bodies in amniocentesis decision making,” Sociology of Health & Illness, Vol. 32, No. 1, 2010: 41.
  8. ^ Rayna Rapp, “Women’s Responses to Prenatal Diagnosis: A Sociocultural Perspective on Diversity,” Journal of Genetic Counseling, Vol. 2, No. 3, 1993: 187.
  9. ^ C.H. Browner et al., “Genetic counseling gone awry: miscommunication between prenatal genetic service providers and Mexican-origin clients,” Social Science & Medicine, Vol. 56, 2003: 1936.
  10. ^ Healy et al., 627.
  11. ^ “Racial & Ethnic Disparities”
  12. ^ “Infant Mortality and African Americans,” The Office of Minority Health, U.S. Department of Health & Human Services, http://minorityhealth.hhs.gov/templates/content.aspx?ID=3021.
  13. ^ “Definition of Congenital Malformation,” MedicineNet.com, http://www.medterms.com/script/main/art.asp?articlekey=2820.
  14. ^ “Infant Mortality/SIDS and Hispanic Americans,” The Office of Minority Health, U.S. Department of Health & Human Services, http://minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=8&ID=3329.
  15. ^ “Infant Mortality and African Americans.”
  16. ^ Healy et al., 628.
  17. ^ Gavin et al., “Racial and Ethnic Disparities in the Use of Pregnancy-Related Health Care Among Medicaid Pregnant Women,” Maternal and Child Health Journal, Vol. 8, No. 3, 2004: 116.
  18. ^ “ABC’s… Pregnancy Tips,” Centers for Disease Control and Prevention, Department of Health and Human Services, http://www.cdc.gov/ncbddd/bd/abc.htm.
  19. ^ Clinical Update: Exercise and pregnancy—what patients need to know. Journal of Musculoskeletal Medicine. 2010;27(4):140, 162.
  20. ^ "Prenatal Care Access Among Immigrant Latinas: Policy Brief.". National Latina Institute for Reproductive Health.. 2005. 
  21. ^ Shaffer, C.F. (2002). "Factors Influencing the Access to Prenatal Care by Hispanic Pregnant Women.". Journal of the American Academy of Nurse Practitioners 14: 93-96. 
  22. ^ Hayes-Bautista, David (2004). La Nueva California: Latinos in the Golden State.. Los Angeles: The Regents of the University of California.. 
  23. ^ "Testing the Epidemiologic Paradox of Low Birth Weight in Latinos.". Pediatric and Adolescent Medicine 153: 147-153. 1999. 
  24. ^ Hayes-Bautista, David (2004). La Nueva California: Latinos in the Golden State.. Los Angeles: The Regents of the University of California.. 
  25. ^ Hayes-Bautista, David (2004). La Nueva California: Latinos in the Golden State. Los Angeles: The Regents of the University of California.. 
  26. ^ "Do Healthy Behaviors Decline with Greater Acculturation?: Implications for the Latino Mortality Paradox.". Social Science & Medicine 61: 1243-1255. 2005. 
  27. ^ "Examining a Paradox: Does Religiosity Contribute to Positive Birth Outcomes in Mexican American Populations?". Health Education Quarterly 22: 96-109. 1995. 
  28. ^ "A Further Examination of the “Epidemiologic Paradox”: Birth Outcomes among Latinas". Journal of the National Medical Association 97: 550-556. 
  29. ^ "The Latina Paradox: An Opportunity for Restructuring Prenatal Delivery Care.". American Journal of Public Health 94: 2062-2065.. 2004. 
  30. ^ Shaffer, C.F. (2002). "Factors Influencing the Access to Prenatal Care by Hispanic Pregnant Women.". Journal of the American Academy of Nurse Practitioners 14: 93-96. 
  31. ^ "Prevalence of low birth weight among Hispanic infants with United States-born and foreign-born mothers: the effect of urban poverty.". Am J Epidemiol 139: 184-192. 1994. 
  32. ^ "Acculturation and the Low-Birth Weight among Latinos in the Hispanic HANES". American Journal of Public Health 79: 1263-1267. 1989. 
  33. ^ "The Latina Paradox: An Opportunity for Restructuring Prenatal Delivery Care.". American Journal of Public Health 94: 2062-2065. 2004. 
  34. ^ Browner et al., 1941.
  35. ^ Rapp, 193.
  36. ^ Anne Witmer et al., “Community Health Workers: Integral Members of the Health Care Work Force,” American Journal of Public Health, Vol. 85, No. 8, 1995: 1056.

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