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and wanted at the time of conception. It is apparent, for example, that both
teenagers and unmarried women experience higher than average rates of
Tow birthweight; they also report higher rates of unintended pregnancies. It
has been suggested that a woman who has planned for and welcomes her
pregnancy will follow the health practices necessary to increase the chances
of a successful pregnancy outcome more aclequately than a woman with an
undesired pregnancy. Recent data from the 1980 National Natality Survey
support this thesis. In the portion of that survey focused on married women
only, wantedness of pregnancy had a strong relationship to seeking prenatal
care. Women who wanted a child at the time they became pregnant were
more likely to receive care early in pregnancy than were those who would
have preferred to have had a chilct at a later time. Women who had not
planned to have another child showed the most delay in seeking prenatal
care. These factors accounted for about a third of the black/white ctifferential
in the number of prenatal visits.~4
Unmet Need for Family Planning
The large number of unintended pregnancies in the United States, the
percentage of women at risk of unintended pregnancy who do not use
contraception, and the number of abortions indicate that existing family
planning strategies are not fully adequate. The reasons for this problem
range from service inadequacies to the knowledge, attitudes, and practices of
inclividual couples.
The unmet need appears to be largest among two groups at particularly
high risk of low birthweight, the poor and the young. It has been estimated
that in 1981, about 9.5 million Tow-income and 5 million sexually active
teenagers neecled subsidized (i.e., supported at least in part by public funds)
family planning care, but over 40 percent of both groups did not obtain
medically supervised contraceptive care.15
For this reason, the committee emphasizes the importance of Title X of the
Public Health Service Act. Title X authorizes project grants to public and
private nonprofit organizations for the provision of family planning services
to all who need and want them, inclucling sexually active teenagers, but with
priority given to low-income persons. The committee urges that federal
funds be made generously available to meet the documented need for family
planning. The Title X program and family planning services generally should
be regarded as important parts of the public effort to prevent low birth-
weight.
The prevention of unwanted pregnancies in sexually active adolescents,
particularly those under 17 who are unmarried, should receive special atten-
tion. Infants born to members of this group have substantially higher rates of
low birthweight, neonatal mortality, and postneonatal mortality and mor-
bidity than infants born to older mothers.
THE IMPACT OF PRENATAL CARE
After a comprehensive review of the literature on the value of prenatal
care, the committee concluded that the overwhelming weight of the evi-
dence is that prenatal care reduces low birthweight. This finding is strong
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enough to support a broad,
national commitment to
ensuring that all pregnant
women in the United
States, especially those at
medical or socioeconomic
risk, receive high-quality
prenatal care.
Prenatal Care Studies
In reaching this con-
clusion, the committee re-
viewed two groups of
studies designed to deter-
mine the value of prenatal
care in the prevention of
Tow birthweight. The first
group consisted of studies
involving large data sets,
usually a year of live births
in a large geographic area
or in the nation as a whole.
The second) includecT stucI-
ies evaluating the impact
on pregnancy outcome of
specific programs offering prenatal care and related services. Conclusions
drawn from both classes of studies are limitect by a variety of problems
inherent in all studies of the effectiveness of prenatal care. These problems,
detailed in the full report, involve difficulties in research design, inadequate
definitions of the content of prenatal care, selection bias, and other issues.
The committee noted that a major theme of virtually all the studies re-
viewed is that prenatal care is most effective in reducing the chance of low
birthweight among high-risk women, whether the risk derives from medical
factors, sociodemographic factors, or both. This finding has important
implications for targeting interventions; it also suggests that differences in
the risk status of various study populations may partially explain variations
in the prenatal care effects observed across studies.
All of the studies reviewed that are basect on large numbers of cases,
particularly those using vital statistics data, show that prenatal care exerts a
positive effect on birthweight. Unfortunately, because content of prenatal
care is not defined carefully in many of these studies, it is not possible to trace
the benefits of care to specific aspects of the total care package.
More variation exists among the results of studies evaluating special pro-
grams, although the majority show that prenatal care is associates! with
improved birthweight. Those special programs that have shown positive
impact on birthweight usually offer prenatal care that goes beyond more
routine services to include flexible combinations of education, psychosocial
and nutrition services, and certain clinical interventions such as careful
screening for medical risks and a rapid response to the first signs of early
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labor. The successful projects also offer a package of services that often is
carefully defined and describec! in written standards.
The limitecl impact of prenatal care suggested by some of the special
programs may result from the fact that the care was not organized to address
what is now known about the causes and risks of Tow birthweight. For
example, the care may not have focused on such factors as smoking reduc-
tion, adequate weight gain, reducing alcohol and other substance abuse,
patient and provider education about prevention of prematurity, or specific
meclical risks associated with low birthweight, such as bacteriuria.
Effect of Prenatal Care on Health Care Expenditures
The economic impact of prenatal care and other strategies to recluce low
birthweight is difficult to evaluate because adequate cost information is
rarely available. Nevertheless, informed public policy requires consideration
of the costs as well as the benefits of proposed health promotion strategies.
The committee found that while it was not possible to complete a formal
cost-effectiveness analysis of each of the strategies it recommended to reduce
Tow birthwei~ht, it was possible to estimate some of the financial imnlica
~ ~ 1 ~ r
.. ~ ... . . . . . . ~ . . . . .
lions or providing prenatal services to certain groups of hlgh-rlsk pregnant
women.
The committee defined a high-risk target population of women with less
than a high school education anc! on welfare, who often do not begin prenatal
care in the first 3 months (trimester) of pregnancy. The current low birth-
weight rate in this group is about Il.5 percent. The committee estimated the
increased expenditures that would be required to provide routine prenatal
care to all members of the target population from the first trimester to the
time of delivery. These expenditures were compared with savings that could
be anticipated through a decreased incidence of low birthweight resulting
from the improved utilization of prenatal care by the target population.
These savings were estimated for a single year and consisted of initial
hospitalization costs, rehospitalization costs, and ambulatory care costs as-
sociated with general illness. The many assumptions that shaped these
calculations are detailed in the report.
The analysis showed that if the expandect use of prenatal care reduced the
low birthweight rate in the target group from Il.5 percent to only 10.76
percent, the increased expenditures for prenatal services would be approxi-
mately equal to a single year of cost savings in direct medical care ex-
penditures for the low birthweight infants born to the target population. If
the rate were reduced to 9 percent (the 1990 goal set by the Surgeon General
for a maximum low birthweight rate among high-risk groups), every addi-
tional dollar spent for prenatal care within the target group would save $3.38
in the total cost of caring for low birthweight infants requiring expensive
medical care.
The committee emphasizes that net savings in government expenditures is
a limited criterion. A society concerned with the health and productivity of
all its citizens might well choose to recluce low-weight births through actdi-
tional investments in prenatal care or other approaches even if the budgetary
outlays were to exceed savings.
Representative terms from entire chapter:
low birthweight
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