Prenatal Care in Utah

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Prenatal Care in Utah

• Utah Department of Health
• Laurie Baksh, MPH
• Kirsten Davis, BS
• Lois Bloebaum, BSN
• Nan Streeter, MS RN
• Robert Rolfs, MD MPH

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Background

• Adequacy of prenatal care is a measure of access
  to prenatal care.
• Inadequate prenatal care (PNC) is a risk factor
  for low birth weight and other adverse pregnancy
  outcomes.
• Prenatal care provides an opportunity to conduct
  risk assessment, risk reduction, and maternal
  education.
• Risk reduction is particularly beneficial to
  medically and socio-economically high risk women.

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Barriers to Prenatal Care

• Previous studies have cited the following as
  barriers to receiving early and adequate PNC
• no regular provider of care before the pregnancy
• lack of transportation
• inability to obtain appointments
• lack of childcare
• fear of disclosure of the pregnancy

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Risk Markers for Inadequate PNC
Previous studies have cited the following
maternal characteristics as barriers to receiving
early and adequate PNC

• low education levels
• multi-parity
• less than 20 years of age
• unmarried
• unwanted or mistimed pregnancies
• having Medicaid or no insurance
• being unemployed

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Healthy People 2010 Goals

• 90 of pregnant women to begin PNC in the first
  trimester of pregnancy.
• 90 of pregnant women to obtain early and
  adequate PNC.

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United Health Group Reports

• The United Health Group State Health Ranking
  Reports of 2000 and 2001 ranked Utah 49th in the
  nation for adequacy of PNC.
• The report stated that 76.4 of US women
  received adequate PNC while only 61.4 of Utah
  women received adequate PNC (source 1999 data,
  CDC).
• Rankings were based upon the Modified Kessner
  Index for adequacy of PNC.

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Modified Kessner Criteria (Kessner, 1973)
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Methodology

• 1999 birth certificate and Utah PRAMS data were
  used to identify characteristics of women who
  received inadequate PNC.
• Variables from Utah birth certificate data used
  in the analyses included
• Number of PNC visits, month PNC began, maternal
  age, education level, race, Hispanic ethnicity,
  marital status, geographic area, number of
  previous live births, and birth interval.

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Methodology (cont.)

• Variables from Utah PRAMS data used in the
  analyses included
• PNC payer type, pregnancy intention, smoked
  cigarettes in 3 months before pregnancy,
  drank alcohol in 3 months before pregnancy,
  annual household income, and timing of
  pregnancy recognition.
• The Adequacy of Prenatal Care Utilization (APNCU)
  Index was used to measure adequacy of PNC in Utah.

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APNCU Index (Kotelchuck, 1994)

• Index Level
• Inadequate After month 4 or less than 50 of
  recommended visits
• Intermediate Before month 5 and 50 - 79
  of recommended visits
• Adequate Before month 5 and 80 - 109
  of recommended visits
• Adequate Plus Before month 5 and 110
  of recommended visits

Based upon ACOG guidelines of 13 visits for a
40 week gestation.
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Adequacy of Prenatal Care in Utah

• APNCU of
• Index Level Women 95 CI
• Inadequate 12.1 ? 2.3
• Intermediate 25.0 ? 2.9
• Adequate 45.2 ? 3.3
• Adequate Plus 17.7 ? 2.5
• Overall, 37.1 of Utah women received less than
  adequate PNC in 1999.

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Adequacy of Prenatal Care in Utah APNCU Index
by Trimester of Entry
APNCU of PNC in 1st PNC After 1st Index
Level Women Trimester Trimester Inadequate 12.1
2.7 9.4 Intermediate 25.0 21.9 3.1
Adequate 45.2 40.9 4.3 Adequate
Plus 17.7 16.2 1.5
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Adequacy of Prenatal Care in Utah - The Big
Picture
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Inadequate Prenatal Care in Utah A Dual Issue

• Two thirds of women who received inadequate
  care entered PNC in the first trimester (11,300)
  but did not obtain a sufficient number of PNC
  visits during their pregnancy.
• About one third of women who received
  inadequate care (5,700) entered PNC after the
  first trimester.
• Further analysis revealed that women from these
  two groups appeared to be demographically
  different from each other.

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Inadequate PNC Due to Insufficient Visits Among
Utah Women

• Women who received inadequate PNC due to
  insufficient visits closely resembled the general
  birth population with the exception of the
  following characteristic
• Previous delivery between 21 and 36 months before
  the current delivery

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Inadequate PNC Due to Late Entry for Subgroups
of Utah Women

• of Women With Inadequate PNC Due to
  Late Entry
• Total Utah Birth Population 12.5
• Urban Residence 15.8
• Pregnancy Unintended 17.9
• Age lt 19 Years 19.4
• Smoked Cigarettes Before Pregnancy 21.1
• Hispanic Ethnicity 21.3
• Medicaid was PNC Payer 22.5
• Education lt 12 Years 23.8
• Unmarried 24.7
• Household Income lt 15,000 24.1
• Birth Interval lt20 Months 28.2
• Other Than White Race 32.6

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Self-Reported Barriers to Early PNC

• 61.1 of women who did not receive adequate care
  due to late entry said they did receive PNC as
  early in their pregnancies as they wanted.
• It appears that many Utah women are not aware
  that first trimester PNC is important.

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PRAMS Survey Question Did you get prenatal care
as early in your pregnancy as you wanted?
Responses limited to women who had inadequate
PNC due to late entry.
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Self Reported Barriers to Early PNC Among Women
Whose Care Was Inadequate Due to Late Entry and
Reported They Wanted to Begin Prenatal Care
Earlier
Responses limited to women who had inadequate
PNC due to late entry.
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Questions That Need to Be Answered

• Why do women with late entry believe they began
  care early enough?
• Are there institutional practices in Utah that
  discourage women from receiving early and
  continuous PNC?
• What does it mean to report no money as a
  barrier to early PNC? Is this a systems issue?
• Why do so many women in Utah not receive enough
  PNC visits?

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Actions

• 2002 PRAMS surveys will be modified to include
  two questions regarding the frequency of and
  barriers to PNC visits.
• Focus groups with women who received inadequate
  prenatal care will be conducted to further assess
  barriers to receiving adequate PNC in Utah.