Prenatal Care: Examining the Evidence for an Evolving Paradigm
Am Fam Physician. 2005 Apr 1;71(7):1264-1266.
The chief objective of prenatal care is to ensure good pregnancy outcomes. The concept evolved significantly in the 20th century, when advances in medical knowledge and practice contributed to a dramatic reduction in maternal and perinatal mortality and morbidity rates. Prenatal care prepares prospective parents for childbirth and permits their active participation in decision-making processes.
There have been significant triumphs. Infant and maternal death rates have dropped dramatically. Stillbirths and newborn deaths resulting from maternalfetal Rh incompatibility and congenital syphilis essentially have become a thing of the past. Improved diabetic control and fetal surveillance techniques have made it possible for women with diabetes to deliver healthy newborns. Screening and appropriate therapy have led to a drastic reduction in the transmission of human immunodeficiency virus from mother to infant. Universal screening of pregnant women for group B streptococcus (GBS) and intrapartum antibiotic therapy have reduced the incidence of early-onset neonatal GBS infection by 70 percent.1 The recommendation that all women intending to conceive should take folic acid preconceptually and in early pregnancy has been associated with a reduction of up to 50 percent in the incidence of neural tube defects. Prospective parents carrying genes for lethal disorders now have numerous screening options. Advances in ultrasound techniques allow physicians to diagnose congenital malformations earlier in pregnancy. Women who have preeclampsia, a condition previously associated with a high perinatal mortality, can be identified and delivered before the disease results in death or harm to mother and infant.
In this issue of American Family Physician, Kirkham and colleagues2 present a broad overview of strategies involved in prenatal care and examine the level of evidence for each of them.
One of the most important goals of prenatal care is recognizing which women have high-risk pregnancies and triaging these women to appropriate care.3 Not all pregnancies carry the same risk. Furthermore, strategies that are appropriate for one high-risk patient may not be appropriate for another.3
Evidence addressing the frequency and number of prenatal visits was reviewed recently by the World Health Organization.4 It was found that a model with a reduced number of antenatal visits could be introduced into clinical practice without risk to mother or baby; reducing the number of visits results in lower costs but less patient satisfaction.4 Satisfaction generally is greater in low-risk pregnant women who are cared for by family physicians or midwives.5
Once identified, women with uncomplicated pregnancies may be triaged to a regimen of fewer prenatal office or clinic visits. In certain geographic regions, family physicians may be the only point of access to prenatal care. To achieve the best pregnancy outcomes, it is important to recognize and refer women who require specialized care.
Major medical challenges remain. Preterm birth, intrauterine growth restriction, and preeclampsia are associated with significant maternal and infant mortality and morbidity. Despite years of research, our understanding of these conditions remains murky, and consequently we have not significantly reduced the incidence of these conditions or their adverse effects.
The persistent disparities in prenatal care remain challenging. It is commendable that 98.9 percent of women in the United States receive prenatal care, with 84.1 percent starting prenatal care within the first trimester.6 However, black women, teenagers, women with addictions, and the poor are at greater risk of receiving late prenatal care or none at all.6 For example, black women are 3.3 times more likely than white women not to have prenatal care (2.7 versus 0.84 percent). Unfortunately, it is these women who are at increased risk of adverse pregnancy outcomes. Clearly, strategies must be devised to improve access to prenatal care for these women.
The future must bring strategies to ensure that all pregnant women receive accessible, individualized care, and medical advances to make reductions in the incidence of challenging conditions such as preterm birth, intrauterine growth restriction, and preeclampsia possible.
1. Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep. 2002;51(RR–11):1–22.
2. Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part 1. General prenatal care and counseling issues. Am Fam Physician. 2005;71:1307–16.,1321–2.
3. Kontopoulos EV, Vintzileos AM. Condition-specific antepartum fetal testing. Am J Obstet Gynecol. 2004;191:1546–51.
4. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357:1565–70.
5. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2001;(4):CD000934.
6. Vintzileos AM, Ananth CV, Smulian JC, Scorza WE, Knuppel RA. Prenatal care and black-white fetal death disparity in the United States: heterogeneity by high-risk conditions. Obstet Gynecol. 2002;99:483–9.
Copyright © 2005 by the American Academy of Family Physicians.
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