Minnesota Title V MCH Needs Assessment Fact Sheets

Pregnant Women, Mothers and Infants

Early and Adequate Prenatal Care

Fall 2004

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Size of the Problem

Minnesota records over 68,000 births annually with an estimated 1,096,832 women of child-bearing age (15-44 years old) residing in the state [1]. In 2002, prenatal care began in the first trimester, as recommended, for 85.5% of pregnancies [2]. This represents over 9,800 births with late (2nd or 3rd trimester) or no prenatal care. Other prenatal risk factors include:

  • During 1996-2002, Minnesota women infected with HIV gave birth to 168 babies [3,4].
  • Based on national estimates, medical complications during pregnancy range between 12%-27% of all deliveries which would represent over 8,000 pregnancies in Minnesota annually [5].
  • The March of Dimes estimates that 1 in 28 babies born each year will have a birth defect. In Minnesota, over 2,400 births would be affected [6].
  • National research indicates that only 30- 40% of women actually have prenatal weight gain within the Institute of Medicine (IOM) guidelines which puts an estimated 40,800 pregnancies each year in Minnesota with inadequate or excessive weight gain during pregnancy [7].

Minnesota uses the prenatal care index, GINDEX, to measure adequacy of prenatal care. Adequacy of care is determined by combining the measures of the month or trimester prenatal care began, the number of prenatal care visits, and the gestational age of the infant/fetus at the time of birth. GINDEX includes gestational age over 36 weeks and the number of prenatal care visits greater than nine to impute adequacy of prenatal care.

Seriousness

Women affected by late or no prenatal care.
Women with late or no care are unlikely to receive the following important components of comprehensive prenatal care:

  • Prenatal genetic testing and counseling to detect birth defects. Each year in Minnesota
    approximately 100 babies die from birth defects representing about 29% of Minnesota’s infant deaths. Most deaths are due to cardiac defects believed to originate from both genetic and environmental causes [1,8]. Neural tube defects (NTDs) affect approximately 30 babies in Minnesota each year [1].
  • Treatment of medical complications including pregnancy-induced hypertension (3.6% of women), diabetes (2.6%), anemia (2%), and chronic hypertension (0.7%) [9]. The most common causes of prenatal hospitalization are preterm labor followed by hypertension, diabetes, bleeding/placenta previa, premature rupture of the membranes [10].
  • Promotion of optimal weight gain during pregnancy remains a challenge for many women. Data from the Minnesota Pregnancy Assessment Form (MPAF) indicate that 9.3% of pregnant women were identified as significantly underweight or overweight during their pregnancy [11]. Women, Infants, and Children Nutrition Program (WIC) participants were more challenged with 29% having excess weight gain as a problem during pregnancy. The data also indicate that 10.9% were underweight and 42.3% were overweight or obese prior to their current pregnancy [12].
  • Testing for sexually transmitted infections and HIV is a recommended practice standard. Nationally, more than 20% of pregnant women have never been tested for HIV, despite Centers for Disease Control (CDC) recommendations [13].
  • Dental health assessment and treatment is important to optimal pregnancy outcome because pregnant women with periodontitis are 7.5 times more likely to have a preterm low-birth weight infant than control subjects [14].
  • Maternal mental health and substance abuse screening/assessment, referral and treatment are also important for pregnant women. According to the 2002 Minnesota Pregnancy Risk Assessment and Monitoring System (PRAMS) data, 76% of mothers with newborns were asked by their provider about “baby blues” and 74% were asked about alcohol use during pregnancy [15].

Disparities
Minnesota’s data on prenatal care come from three sources: Medical Assistance participants, WIC Program participants, and birth certificates. Each data set measures slightly different indicators of late or inadequate prenatal care.

According to data from the Minnesota Department of Human Services (DHS), rates of inadequate prenatal care are greater for all low income women on Medical Assistance depicted in the graph below.

Late or Inadequate Prenatal Care Among Minnesota Public Program Participants, 1998-2001
Prenatal Care Percent
Inadequate prenatal care (< 2 visits in 2nd or 3rd trimester)
8.9%
Initial prenatal visit > 20 weeks
12.8%
Source: DHS Mn Pregnancy Assessment Form, 1998-2001. 2003 [11].
N=54,309 pregnant women on Medical Assistance

According to Minnesota birth certificate data, rates of inadequate/no prenatal care are 3-4 times higher among populations of color in Minnesota compared to rates of white pregnant women. women [16]. While some trends show improvement, the rates for Hispanic pregnant women appear slower to improve.

Inadequate or No Prenatal Care
Race/Ethnicity 1989-1993 1997-2001
African American 20.1 12.4
American Indian 27.2 17.4
Asian 20.6 9.8
Hispanic 14.7 11.2
White 3.3 3.2
Source: MDH. Populations of Color in Minnesota - Health Status Report. Update Summary. Fall 2003. (GINDEX)

Maternal infections and disease have significant impact during pregnancy:

  • Nearly 19,000 US women are Hepatitis B carriers; 46% of those are SE Asians compared to 21% of whites, 19% blacks, 11% Hispanics, and 3% others [16].
  • Group B streptococcal disease (GBS) is a leading cause of early neonatal infection and death in the US for infants <7 days old. Black infants are at higher risk than white infants [17].
  • Perinatal transmission of the mother’s HIV infection to the baby disproportionately affects racial and ethnic communities: 36% of the babies born to mothers infected with HIV in Minnesota over the past seven years were born to African American women [3].
Intensive or Adequate Prenatal Care in Minnesota by Race/Ethnicity
Race/Ethnicity 1997-2001 1989-1993
White
80
78.4
Hispanic
54.4
51.8
Asian
57
43.1
American Indian
49.2
37.3
African American
57.1
47
Source: MDH. Populations of Color in Minnesota - Health Status Report. Update Summary. Fall 2003. (GINDEX)
  • Women of color were more likely than white mothers to be diagnosed with HIV after the birth of an infected baby.
  • American Indian pregnant women in Minnesota were found to have a diabetes-complicated rate of 93 per 1,000 live births. This rate is three times higher than the non-Hispanic white rate [18].
  • Research has indicated that Hispanic women, particularly women of Mexican descent, are more at risk of Neural Tube Defects than non-Hispanic women [19].
  • Disparities in geographic access to genetic counseling exist as genetic services are limited to the Twin Cities, Duluth, Rochester, and St. Cloud.

Economic
The cost effectiveness of early and adequate prenatal care has been well documented:

  • The CDC has estimated a savings of $14,755 per low birth weight birth prevented (in 1984 dollars) if all US women received adequate prenatal care [20].
  • Intensive diabetes management prior to conception and during pregnancy was found to save $5.19 for every $1 spent on the program (1990 dollars) [21].
  • The estimate of total, lifetime costs to Minnesota for 12 common birth defects that occur each year was calculated at $131 million [22].

Interventions

  • Nationally, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have collaborated in publishing Guidelines for Perinatal Care which addresses the need for early and adequate prenatal care [23].
  • The Minnesota-based Institute for Clinical Systems Improvement standards for prenatal care has a strong emphasis on early and adequate prenatal care [24].
  • The Association of State and Territorial Health Officials issued a policy statement in 2003 that recommends, “Expand access to prenatal care services through targeted outreach and intervention” [25].
  • Minnesota’s Hepatitis B Perinatal Prevention program, funded by the CDC recommends early screening of all pregnant women, education, immunization, and contact tracing.
  • The CDC currently recommends routine voluntary prenatal HIV-1 testing, preferably using the “opt out” consent, for all women in the United States with routine screening of infants whose mothers were not screened [26].
  • The IOM guidelines for adequate weight gain during pregnancy have been adopted by the national WIC Programs.

Effectiveness of Interventions
The CDC has documented the effectiveness of early and adequate prenatal care [27]. Numerous studies have documented the effectiveness of adequate prenatal weight gain on pregnancy outcome [28].

Additionally, studies have documented the effectiveness of intervention programs for diabetes control during pregnancy and other medical complications during pregnancy [21,24,29].

Status

Minnesota Resources
Public health has programs and strategies that promote early and adequate/comprehensive prenatal care including:

  • Public health nurse home visiting programs;
  • WIC programs;
  • Twin Cities Healthy Start;
  • Health Plan Perinatal Incentive Programs;
  • Maternity Case Management Project;
  • Culturally specific programs to reduce infant mortality funded by MDH’s Eliminate Health Disparities Initiative(EHDI);
  • Southwest MN Integrated Prenatal Project;
  • Doula Programs;
  • The Nest Incentive Programs;
  • Tribal Health Initiatives;
  • Local public health improved pregnancy outcome (IPO) projects;
  • Expanded authorization for dental hygienists and expanded duties for dental auxiliary;
  • Dental practice donation program;
  • Dentist loan-forgiveness program; and
  • Access to genetic counselors and geneticists in Minnesota Level III Perinatal Centers located at eight hospitals: five in the Twin Cities and one each in Rochester, Duluth, and St. Cloud.

Community Awareness
There is evidence that some women and providers believe that healthy women who have had a healthy birth can delay care until the second trimester even though research shows that early prenatal care leads to better outcomes.

A study of barriers and motivators for prenatal care conducted among low income women in Minneapolis in the late 1980s determined that the primary reason women delay getting care is their ambivalence about their pregnancy. Other barriers included not being insured and need for transportation and child care [30].

In greater Minnesota, a shortage of prenatal providers, long distances to travel, and a reluctance to apply for state-funded insurance even when eligible have all been described and reported as barriers [31].

References

1. Minnesota Center for Health Statistics. 2003
2. PeriStats. March of Dimes. State data. MN. 2002. Accessed 9-04.
3. MDH. Births to HIV-Infected Women and Perinatal HIV Infections, Minnesota 1996-2002. 2004.
4. MDH. STI and HIV Annual Reports for Minnesota. 2000, 2001, 2002, 2003.
5. Bennett T, Kotelchuck M, Cox CE, Tucker MJ, Nadeau DA. Pregnancy-associated hospitalizations in the United States in 1991 and 1992: a comprehensive view of maternal morbidity. Am J of Obstet and Gyn. 178:346-354. 1998.
6. March of Dimes Resource Center. www.modimes.org [Attn: Non-MDH Link]
7. Hickey CA, McNeal SF, Menefee L, Ivey S. Prenatal weight gain within upper and lower recommended ranges: effect of birthweight on black and white infants. Obstet Gynecol. 1997. 90:489-94.
8. Petrini et al. 2002. Contribution of birth defects to infant mortality in the US. Teratology. 66:S3-S6.
9. Issues in Pregnancy Care. Women’s and Children’s Health Policy Center. Johns Hopkins University. 1999.
10. Bennett T, Kotelchuck M, Cox CE, Tucker MJ, Nadeau DA. Pregnancy-associated hospitalizations in the United States in 1991 and 1992: a comprehensive view of maternal morbidity. Am J of Obstet and Gyn. 178:346-354. 1998.
11. DHS. Minnesota Pregnancy Assessment Form Report #2: Managed Care Organizations and Fee-for-Service Data for 1998-2001. September 2003.
12. CDC. Pregnancy Nutrition Surveillance System for 2002. Minnesota Data. 2003.
13. CDC. National Center for Infectious Diseases. Addressing the Problem of Diseases of Pregnant Women and Newborns. 9-11-00 Accessed.
14. Krejci,CB, Bissada,NF. Women’s health issues and their relationship to periodontitis. JADA. March 2002. 133:323-329.
15. MDH. Initial Findings from the Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS)- 2002. August 2004.
16. MDH. Populations of Color in Minnesota Health Status Report- Update Summary. Fall 2003.
17. CDC. Diminishing racial disparities in early-onset neonatal group B streptococcal disease-United States, 2000-2003. MMWR 6/18/04, 502-509.
18. MDH. Diabetes Among American Indians in Minnesota. January 2001.
19. Shaw et al. 1997. Risk for neural tube defect-affected pregnancies among women of Mexican descent and white women in California. AJPH Vol.87 (9):1467-1471.
20. CDC. An ounce of prevention: What are the returns? October 1999.
21. Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: The cost-effectiveness of the California diabetes and pregnancy program. Am J of Public Health 82(2):168-175. 1992.
22. http://healthyamericans.org/state/birthdefects/ [Attn: Non-MDH Link] Accessed 7/04.
23. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). 2002. Guidelines for Perinatal Care. Washington, DC.
24. Institute for Clinical System Improvement. Routine Prenatal Care. 2003. www.ICSI.org [Attn: Non-MDH Link]
25. Association of State and Territorial Health Officials. State Policy Options to improve Birth outcomes. October 2003.
26. CDC. Advancing HIV prevention: new strategies for a changing epidemic-U. S. 2003. MMWR 2003.52:329-332.
27. CDC. 1999. Healthier mothers and babies. MMWR 48(38):849-859.
28. Hickey CA, Kreauter M, Bronstein J et al. Low prenatal weight gain among adult WIC participants delivering term singleton infants: Variation by maternal and program participation characteristics. Mat and Child Health J. 3(3):129-140. 1999.
29. MMWR. Diabetes during pregnancy- United States 1993-1995. 47(20):408-415.May 1998.
30. Lia-Hoagberg B. et al. Barriers and motivators to prenatal care among low income women.1990. Soc. Sci. Med. Vol.30:4. pp 487-495.
31. Reports of the St. Louis County (1999) and SE MN (1997-98) Fetal and Infant Mortality Review (FIMR) projects. Available from MDH, MCH Section.