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his article explores factors related to inadequate prenatal care and identifies ways nurses can influence these. In the field of obstetrics, obstetric nursing, and public health, the importance of early, adequate prenatal care is well documented (Ingram, Makuc, & Kleinman, 1986; Merkatz, Thompson, Mullen, & Goldenberg, 1990; Moore, Origel, Key, & Resnik, 1985). Prenatal care is considered adequate when it begins in the first trimester of pregnancy and continues on a regular basis every 4 weeks until 28 weeks, then every 2 weeks until the 36th week, and weekly thereafter (American College, 1988). The amount of prenatal care should vary, depending on the risk status of the pregnant woman (Merkatz et al., 1990). However, adequate prenatal care is not accessible to all women in the United States, and when it is accessible, it is not always used.

Prenatal care History The importance of prenatal care was first realized in the early 1900s and is attributed to a societal concern for healthy infants and good outcomes for childbearing women (Merkatz et al., 1990). The provision and use of prenatal care increased slowly from the 1930s until 1980 (Hemminki, McNellis, & Hoffman, 1987). In the 1970s, the percentage of both black and white mothers seeking early prenatal care increased annually. In the United States, prenatal care is not used by all pregnant women.

Inadequate prenatal care is one of the most perplexing problems in obstetrics. Many women do not seek prenatal care early, and some obtain no prenatal care. The history of prenatal care, the impact of inadequate prenatal care, and the many factors involved in access to and use of prenatal care are discussed. Nursing implications aimed at exploring ways of reducing these factors are examined.

However, from 1980 until 1983, a decline in the initiation of prenatal care in the first trimester by black mothers was observed, with no similar change observed in the initiation of early prenatal care by white mothers. The group obtaining early prenatal care least frequently comprised unmarried black teenagers with less than a high school education (Ingram et al., 1986). In the United States, approximately 5-6% of all pregnant women do not seek prenatal care until the third trimester or obtain no prenatal care (Brown, 1989; Young, McMahon, Bowman, & Thompson, 1989).

Accepted: January 1992

Characteristics Frequently, the focus of prenatal care concerns the collection and evaluation of laboratory values and physical measurements. This approach provides little

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in the way of health education, counseling, and social support. Prenatal care should identify problems associated with pregnancy, provide education and support for the woman during pregnancy, and prepare her for proper child rearing (Hemminki, 1988). Nationally, an expert panel identified three basic components of prenatal care: early and continuing risk assessments, health promotion, and medical and psychosocial interventions with follow-up (Expert Panel, 1989).

Impact of Inadequate Prenatal Care Patients who do not receive the prenatal care they need increase their risk of a poor pregnancy outcome (Moore et al., 1985). The inadequate use or lack of prenatal care is associated with a greater number of maternal and fetal complications (Cramer, 1987; Moore et al., 1985). Lack of prenatal care is associated with low birth weight and an increased incidence of prematurity in neonates (Davis, Fink, Yesupria, Rajegowda, & Lala, 1986; Institute of Medicine [IOM], 1985). A strong association also has been found between these two complications and infant mortality (IOM, 1985). Conversely, the use of prenatal care is associated with a lower infant mortality rate (National Commission [NCPIM], 1988). In 1988, the infant mortality rate in the United States was 10 per 1,000 live births. This rate is higher than that of many other industrialized nations and ranks the country 18th among 36 such nations (NCPIM, 1988). Tbe use of prenatal care is associated witb a lower infant mortality rate.

Low birth weight and prematurity place a financial burden on the nation. Lifetime health-care costs for an infant of low birth weight could reach as high as $400,000. In the United States, 11,000 low-birthweight neonates are born with long-term disabilities, and because of these disabilities, an additional $3.7 billion is lost in earnings (IOM, 1985). Every delivery of a low-birth-weight newborn that is prevented would save the U.S. health-care system between $14,000 and $30,000. Nationally, for each additional $1 spent on prenatal care, a savings of $3.38 would be yielded for the health-care system (IOM, 1985). The foregoing are strong reasons for seeking prenatal care; yet many do not obtain adequate care, especially early in pregnancy. In 1986, only 76% of all U.S. infants were born to mothers who initiated prenatal care in the first trimester of pregnancy (Brown, 1989).

July/Augwt 1992

Factors Related to Inadequate Prenatal Care Numerous factors are related to inadequate care. These factors have been organized into three main categories: sociodemographic, system-related, and attitudinal (Brown, 1989). Sociodemographic factors consist of minority status, poverty, age, marital status, education, area of residence, high parity, and being non-English speaking. Brown (1989) notes that only 47% of black women aged 15 to 19 years begin prenatal care in the first trimester, and 15% either initiate care in the third trimester or obtain no care. Scholl, Miller, Salmon, Cofsky, and Shearer (1987) observe that approximately 9.5%of pregnant adolescents do not obtain prenatal care until the third trimester. Cramer (1987) reports that the infant mortality rate is higher for teenagers, blacks, unwed mothers, and mothers of a low socioeconomic status. Area of residence also can affect the use of prenatal care. Rural populations already have a number of predisposing prenatal risk factors. Many rural populations are of low socioeconomic status, with obstetric care frequently limited by lack of health insurance and by great distances to travel to health-care providers. Because of the rising costs of malpractice insurance, many rural physicians do not provide obstetric services (Bushy, 1990). According to Fingerhut, Makuc, and Kleinman (1987), a woman with less than a high school education is more likely to have delayed prenatal care and to require public assistance. Other researchers recognize sociodemographic factors as major contributors to inadequate prenatal care, but support the concept that the problem is multifactorial in origin (McDonald & Coburn, 1988; Schwethelm, Margolis, Miller, & Smith, 1989). System-related factors also may determine the timing of initiation and the adequacy of prenatal care. Low-income women are especially subject to these factors, as they tend to have little or no third-party payment mechanism, often lack access to transportation, and may be unable to find a medical provider willing to accept Medicaid (Brown, 1989). Public health departments may be underfunded, overcrowded, and inadequately staffed, resulting in inconvenient hours and increased waiting time for an appointment or in the clinic to see the provider. These factors often result in a negative staff attitude (Schwethelm et al., 1989). Young et al. (1989) explored the reasons for the late entry into prenatal care of 201 new prenatal patients and found that patients’ financial constraints and

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Many factors are related to inadequate prenatal care.

lack of education are reasons for the delay. Factors related to the health-care system also have been reported as significant determinants of the use of prenatal care (Brown, 1989). System-related factors such as financial and administrative problems play a significant role in determining the adequacy of and delay in initiating prenatal care. The Medicaid eligibility requirements related to socioeconomic status also can be categorized as health-care system-related factors (Fingerhut et al., 1987; McDonald & Coburn, 1988). Schwethelm et al. (1989) report that Medicaid recipients are less likely than patients with private insurance to initiate prenatal care during the first trimester and significantly more likely to begin care in the third trimester. Medicaid patients are at risk for poor pregnancy outcomes and, overall, deliver neonates that may be 200 g lighter than neonates born to women with health insurance. Some physicians have reduced their obstetric caseload by limiting or refusing care to low-income clients, who are likely to present with greater medical risks (Schwethelm et al., 1989). Among the attitudinal factors that have been shown to influence whether a patient applies for prenatal care are an unplanned pregnancy, an indifferent attitude toward prenatal care, inadequate social supports or personal resources, failure to notice the signs of pregnancy, and fear of parental discovery (Brown, 1989). Young et al. (1989) found that inability to accept the pregnancy was the reason most reported for delaying care. Lack of knowledge and misguided attitudes about pregnancy are equally important in hindering access to prenatal care services for specific groups (McDonald & Coburn, 1988). Chisholm (1989) reports that not recognizing the pregnancy earlier and being afraid or not wanting to visit the physician are often reasons for seeking prenatal care late. For teenagers, high rates of late participation in prenatal care are related to unplanned, unwanted pregnancies, which are often denied and concealed. No single factor is responsible for inadequate use of prenatal care. Thus, expanding coverage of Medicaid for pregnant women may improve access to prenatal care, but the pregnant woman still may need additional motivation to realize the need for improved access. Teaching patients could affect their attitudes toward prenatal care. Specialized care with additional

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social support should be made available to all low-income women in need of prenatal services. Nurses are an invaluable resource for providing prenatal education and care to all women.

Nursing Implications Nurses need to be more involved in providing prenatal care. All types of nurses-but particularly specialized nurses-could have a strong impact on improving access to and use of prenatal care. Regarding the sociodemographic factors related to poor pregnancy outcome, nursing groups could support legislation to make policy changes to include more health education in schools. If given the opportunity, school-based nurses could provide family planning and counseling services aimed at preventing pregnancy. Classes emphasizing the importance of planned pregnancy and early comprehensive prenatal care would be appropriate for all adolescents, including males. Nurse educators could be available to assist in health promotion classes. Nurses, especially advanced practice nurses, need to be more accessible as primary providers of prenatal care.

System-related factors could be especially affected by nurses in advanced practice. Nurses can provide many primary-care services as well as and less expensively than physicians can (Griffith, 1985). By doing so, they would increase the number of primary care providers available for prenatal care. Nurses not only are competent to perform physical assessments, but focus more on psychosocial support, counseling, and education. With these skills, nurses are the ideal providers for preventing complications and improving patient compliance. Certified nurse-midwives and other nurses have shown that they can affect pregnancy outcomes positively (Piechnik & Corbett, 1985; Slager-Earnest, Hoffman, & Beckmann, 1987; Smoke & Grace, 1988). If advanced practice nurses were more accessible as primary providers, Medicaid patients could seek prenatal care earlier and might not be at increased risk for poor pregnancy outcomes. Nursing groups on state and national levels could help pass legislation to support the role of advanced nursing practice. This could be accomplished by supporting changes in nursing practice acts, third-party reimbursement, and the organizational structure for the delivery of prenatal care. Comprehensive prenatal care is needed for lowincome women, especially teenagers. A combined

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Nurses can influence the use of early prenatal care by all women, thereby improving pregnancy outcomes.

medical and nursing team approach could be used for providing prenatal care, with other professionals consulted as needed. Obstetric nurses and nurse practitioners could collaborate with physicians and complement their expertise. As a result, patients would receive better and more individualized care (Silver & McAtee, 1988). Nurse administrators could influence other system-related factors directly by increasing services to include evening clinics and by seeking additional funding for adequate staffing. In-service training aimed at developing positive staff attitudes and improving staffing patterns could be instituted. All nurses could serve as referral agents for public services available to pregnant women, such as the nutrition program for women, infants, and children; Medicaid; and transportation services. Establishing childcare services at clinics would help pregnant women keep appointments. Home health-care nurses could help provide prenatal care to maternity patients in rural areas. Patients’ attitudes could be influenced by all nurses promoting the importance of early prenatal care. A nurse of the same racial or ethnic background as a particular patient may be more effective in altering the patient’s attitude than would a nurse of a different race or ethnicity. Nursing research is needed to explore what might be effective in attracting women to prenatal care, especially in early pregnancy. Nurse researchers need to evaluate ways to influence women’s perceptions that prenatal care is useful and necessary. Nurses also can investigate ways to decrease system-related factors, such as lengthy waiting times and negative staff attitudes. Persuading women to seek early prenatal care will allow identification of risk factors and improve pregnancy outcomes. The improved access to and use of prenatal care generated by more and better nursing interventions will advance the professional role of nursing. The major responsibility for routine prenatal care could be held by nurses, including nurse practitioners and certified nurse-midwives, with their work supported by physicians in the event of medical problems.

Conclusions Early, adequate prenatal care has shown promising results in improving pregnancy outcomes in the United

July/August 1992

States. However, access to and use of prenatal care for low-income women remains a problem. Nursing research is needed to explore ways to remove barriers to this care. Promoting and providing such care presents an exciting and challenging opportunity for obstetric nursing.

References American College of Obstetricians and Gynecologists. (1988). Guidelinesfor prenatal care. Washington, DC: Author. Brown, S. (1989). Drawing women into prenatal care. Family Planning Perspectives, 2 1 ( 2 ) , 73-80. Bushy, A. (1990). Rural determinants in family health: Considerations for community health. Family and Community Health, 12(4), 29-38. Chisholm, D. K. (1989). Factors associated with late booking for antenatal care in central Manchester. Public Health, l03(6),459-466. Cramer, J. C. (1987). Social factors and infant mortality: Identifying high-risk groups and proximate causes. Demography, 2 4 ( 3 ) , 299-322. Davis, J. K., Fink, R., Yesupria, A., Rajegowda, B., & Lala, R. (1986). Teenage pregnancy in an urban hospital setting. Journal of Community Health, 11(4),259-267. Expert Panel on the Content of Prenatal Care. (1989). Caring for our future: The content ofprenatal care. Washington, DC: Public Health Service. Fingerhut, L. A., Makuc, D., & Kleinman, J. C. (1987). Delayed prenatal care and place of first visit: Differences by health insurance and education. Family Planning Perspectives, 13(5), 212-214, 234. Griffith, H. (1985). Who will become the preferred providers? American Journal of Nursing, 85(5), 538-542. Hemminki, E. (1988). Content of prenatal care in the United States. Medical Care, 26(2),199-210. Hemminki, E., McNellis, D., & Hoffman, H. J. (1987). Patterns of prenatal care in the United States. Journal of Public Health Policy, 8(3), 330-350. Ingram, D. D., Makuc, D., & Kleinman, J. C. (1986).National and state trends in use of prenatal care, 1970-83. American Journal ofpublic Health, 76(4), 415-423. Institute of Medicine. (1985). Preventing low birth weight. Washington, DC: National Academy of Sciences. McDonald, T. P., & Coburn, A. F. (1988).Predictors of prenatal care utilization. Social Science andMedicine, 2 7 ( 2 ) , 167-172.

Merkatz, I. R., Thompson, J. E., Mullen, P. D., & Goldenberg, R. L. (1990). New perspectives on prenatal care. New York: Elsevier. Moore T. R., Origel, W., Key, T. C., & Resnik, R. (1985). The perinatal and economic impact of prenatal care in a lowsocioeconomic population. American Journal of Obstetrics and Gynecology, 154(1), 29-33. National Commission to Prevent Infant Mortality. (1988). Infant mortality: Carefor our children, care for our future. Washington, DC: Author.






Piechnik, S. L., & Corbett, M. A. (1785). Reducing low birth weight among socioeconomically high risk adolescent pregnancies. Journal of Nurse-Midwifery, 30(2), 88-77. Scholl, T. O., Miller, L. K., Salmon, R. V., Cofsky, M. C., & Shearer, J. (1787). Prenatal care adequacy and the outcome of adolescent pregnancy: Effects on weight gain, preterm delivery, and birth weight. Obstetrics and Gynecology, 6 9 3 1 , 312-315. Schwethelm, B., Margolis, L. H., Miller, C., & Smith, S. (1987). Risk status and pregnancy outcome among Medicaid recipients. American Journal of Preventive Medicine, 5(3), 157-163. Silver, H. K., & McAtee, P. (1788). Should nurses substitute for house staff? American Journal of Nursing, 88( 12), 1671-1673. Slager-Earnest, S. E., Hoffman, S., &L Beckmann, C. (1787). Effects of a specialized prenatal adolescent program on maternal and infant outcomes. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 16, 422-427.

Smoke, J., & Grace, M. C. (1788). Effectiveness of prenatal care and education for pregnant adolescents. Journal of Nurse-Midwifery, 33(4), 178-184. Young, C., McMahon, J. E., Bowman, V., & Thompson, D. (1787). Maternal reasons for delayed prenatal care. Nursing Research, 38(4), 242-243.

Address for correspondence: Patsy McClanahan, RNCNP, MSN, Instructor, Obstetrics and Gynecology Department, E. A. Conway Memorial Hospital Division, PO Box 1881, Monroe, LA 71201.

Patsy McClanahan is an instructor in the obstetrics and gynecology department of Louisiana State University Medical Center-E. A . Conway Memorial Hospital Division in Monroe, Louisiana. Ms. McClanahan is a member of NAACOG.

CALL FOR MANUSCRIPTS Authors are invited to submit manuscriptson research, clinical practice, case studies, and thoughts and opinions that incorporate views, experiences, and knowledge in the nursing care of women, childbearing families, and infants. Topics currently holding high interest for JOGNN readers:

Women's Health

Childbearing Families

Women and chronic illnesses (e.g.. heart disease, lung cancer) Alcohol abuse in women Domestic violence Work and family issues Health policy affecting families AIDS prevention and protection Gynecologic surgery Breast care Menopause Aging

Infertility and related technologies Surrogacy Ethics: maternal-fetal conflicts Access to care in urban and rural communities Critical care obstetrics Contraception Fathering

Neonatal Nursing

Professional Issues

Nurses' roles, especially in primary care Legal issues Creative nursing care delivery models Political and legislative issues

Drugexposed neonates Outcomes of care Chronically ill neonates Caring for the very low birth weight infant Innovative therapies (e.g., ECMO)

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Improving access to and use of prenatal care.

Inadequate prenatal care is one of the most perplexing problems in obstetrics. Many women do not seek prenatal care early, and some obtain no prenatal...
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