Prenatal Care

The 1980s saw a proliferation of public and private efforts to increase access to comprehensive prenatal care, as health experts concluded that such care was the public health solution for reducing the high infant mortality rates in the United States and for decreasing racial disparities in poor birth outcomes. The seminal 1985 Institute of Medicine report on Preventing Low Birthweight (LBW), in particular, strongly encouraged public efforts to increase the availability and comprehensiveness of prenatal care to reduce LBW. The report noted that prenatal care was widely perceived to be effective at reducing LBW and was cost effective ($3.38 saved for every dollar spent); it envisioned a more comprehensive version of prenatal care with strong psychosocial content.

Numerous federal, state, and philanthropic efforts were undertaken in this period. The U.S. National Commission to Prevent Infant Mortality was established; the Healthy Mothers, Healthy Babies Coalition was formed; the March of Dimes initiated the program Toward Improving the Outcome of Pregnancy; numerous state infant mortality commissions were started; and several new federal infant mortality reduction programs were undertaken (e.g., Healthy Futures/Healthy Generations, Healthy Start Initiative). A major federal report on the Content of Prenatal Care, published in 1989, also increased the focus on psychosocial and comprehensive prenatal care.

The most significant achievement of this period was the expansion of Medicaid in the late 1980s, which increased eligibility for prenatal care services by delinking Medicaid eligibility from welfare eligibility (specifically, the Aid to Families with Dependent Children program), and fostered more comprehensive prenatal care by allowing Medicaid to pay for numerous nonmedical prenatal services. Medicaid now could enroll and pay for the costs of prenatal care and delivery of all poorer women (those with an income of less than 185 percent of the poverty level), regardless of their marital status. Medicaid could also pay for any case-management, home visitation, nutrition, social work, and health education services that are needed. By the early twenty-first century, Medicaid was covering the costs of more than 40 percent of births in the United States.

In 1980, the U.S. government set as one of its 1990 National Health objectives that 90 percent of all pregnancies begin prenatal care in the first trimester. By the end of the twentieth century, the United States had still not reached this goal, and it therefore became a Healthy People 2010 objective. According to federal statistics from 1998, 82.8 percent of all mothers began prenatal care in the first trimester. This figure rose steadily in 1990s from 75.8 percent, after a decade-long period of no change. The increase in early usage was most likely due to the numerous federal efforts initiated in the late 1980s. The figures also revealed substantial disparities by race: 87.9 percent of white mothers started prenatal care in the first trimester, There has been a recent refocusing of prenatal care to address issues of maternal health, such as diabetes, obesity, and hypertension. For many women, regular exercise and careful dietary controls throughout pregnancy have led to better overall maternal health. (Owen Franken/Corbis) compared to 73.3 percent of black, 74.3 percent of Hispanic, and 83.1 percent of Asian mothers.

More comprehensive utilization measures, such as the Kotelchuck Adequacy of Prenatal Care Utilization (APNCU) Index, also use number of visits and length of gestation, in addition to the timing of initial care, to assess the ACOG prenatal care standards. These indexes suggest an even more somber picture of prenatal care usage in the United States. For example, the APNCU Index reveals that only 74.3 percent of pregnant women have adequate prenatal care, 13.8 percent intermediate care, and 16.9 percent inadequate care, with correspondingly worse figures for African Americans, Hispanic Americans, and Asian Americans. Interestingly, more than 31 percent of U.S. women have more than the ACOG recommended number of visits, a percentage that increased substantially from the 24 percent level of 1990.