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OCR for page 27
27
be learner! from existing experience with the regionalization of perinatal
services; (3) how to make state and national data systems more useful in
assessing unmet need for prenatal services ancI, more generally, in monitor-
ing the impact of various maternal and child health programs; and (4) how to
ensure that prenatal care is financed ad equately in times of cost containment,
when preventive services often lose the competition for dollars.
IMPROVING THE CONTENT OF PRENATAL CARE
Participation in conventional prenatal care programs is associated with a
reduced incidence of low birthweight. The committee believes, however,
that enhancing the content of prenatal care could increase its contribution to
the development of healthy infants. This section focuses on ways to
strengthen prenatal care for all women, for women at elevated risk of pre-
term delivery, and for women at elevated risk of intrauterine growth retarda-
tion (lUGR). It also examines interventions closely associated with prenatal
care that may help to reduce low birthweight, inclucling smoking reduction
programs, nutritional services, and stress alleviation approaches. Finally,
recommendations are made for specific actions on content of care issues by
the federal government and by professional societies representing the major
maternity care providers.
Revisions In Care For All Pregnant Women
The committee has identified seven components of the prenatal care
offered to all pregnant women that merit increased emphasis in the effort to
improve pregnancy outcome generally and to prevent preterm delivery and
{UGR in particular.
1. Establishing Specific Goals
Greater efforts to organize prenatal care
around explicit goals can help focus the attention of the patient on the
purposes of the prenatal visits and engage her more in her own care. The
process of establishing goals also can help the practitioner to structure
appropriate interventions and to consider the combination of prenatal serv-
ices that should be provided to each pregnant woman.
Defining the prevention of Tow birthweight as a major goal of prenatal care
may require adjustments in clinical practice. For example, reducing the risk
of prematurity or JUGR may require more emphasis on screening and
counseling early in pregnancy. At present, prenatal care seems particularly
oriented toward the prevention, detection, and treatment of problems that
are manifested in the third trimester, particularly preecIampsia thus the
emphasis on blood pressure monitoring, screening for proteinuria, attention
to possible eclema, and increased frequency of prenatal visits toward the end
of pregnancy. By contrast, the goal of preventing low birthweight requires
additional attention during the first and second trimesters especially, to
screening, diagnosis, and treatment, as early as possible, of conditions that
predispose to preterm labor or lUGR, such as smoking and poor nutritional
status. Many of the other aspects of prenatal care outlined below also merit
attention early in pregnancy, such as the education topics.
OCR for page 28
28
2. Risk Assessment Prenatal care should include formal identification anct
evaluation of risk. This should be a dynamic process that begins at the first
visit and is attentive to developing problems throughout pregnancy. Risk
assessment can help to increase the flexibility of prenatal care, which is
especially important for women in socially disadvantaged hi~h-risk shrouds:
1 , 1 ~ --a ~ ~-~---~ Or
. . ~ . ~ . . .
set packages of prenatal care often do not address their multiple problems. It
can also help ensure that certain problems and risk factors are both detected
and managed properly.
3. Pregnancy Dating Accurate dating of pregnancy is a cornerstone of
good prenatal care. Without it, a clinician is less able to detect intrauterine
growth retardation, to determine if labor is premature and the extent of the
prematurity, or to avoic! accidental prematurity following labor induction or
an elective cesarean section.
The minimum data required to determine gestational age include the date
of the last menstrual period, uterine size by pelvic exam during the first
trimester, the time of quickening, the first time fetal heart tones are heard
without amplification, and serial fundal height measurements after 20 weeks
gestation.
4. Ultrasound Imaging A federal consensus development conference in
1984, sponsored jointly by the National Institutes of Health and the Food and
Drug Administration, concluded that available data do not support routine
ultrasounc! examination of all pregnancies, but identified almost 30 specific
situations in which ultrasound is useful.18 Among these are many indica-
tions relevant to the prevention of low birthweight. For example, when a
uterine size/ciate discrepancy occurs, ultrasound can help establish gesta-
tional age.
5. Detection and Management of Behavioral Risks Prenatal care should in-
clude explicit attention to detecting and managing behavioral risks associ-
ated with low birthweight, especially smoking, nutritional inadequacies,
and moderate-to-heavy alcohol use. In many settings, intervention options
to overcome these problems are limited to physician or nurse counseling; in
others, more formal programs are available on a referral basis.
6. Prenatal Education Health education for women who are pregnant or
contemplating pregnancy should be expanded to include greater emphasis
on behavioral risks in pregnancy, early signs and symptoms of pregnancy
complications such as preterm labor, the role that prenatal care plays in
improving the outcome of pregnancy, and related topics cletailed in the main
report.
Unfortunately, prenatal care education and counseling services are often
inadequate, particularly for high-risk groups. Problems that may interfere
with effective education of pregnant women include the short time typically
scheduled for each prenatal visit, third-party reimbursement policies that
pay for diagnostic and therapeutic procedures but ignore provider costs
related to patient education, and lack of patient-education interests and skills
on the part of many physicians. in many settings, nurses and relatecl person-
nel may be more appropriate than physicians as providers of prenatal educa-
tion.
Childbirth education classes have not been shown to have an impact on
the incidence of low birthweight, probably because they usually begin in the
third trimester of pregnancy and focus primarily on labor and delivery. To
OCR for page 29
increase their role in the pre-
vention of low-weight births,
these classes should begin
earlier, place greater empha-
sis on the prenatal period and
the risk factors described
above, and make a greater
effort to enroll women from
lower socioeconomic groups.
7. Health Care System Fac-
tors Prenatal care providers
should organize their pro-
grams to manage a wider
variety of patient problems
and risk factors than is usual-
Ty possible in many prenatal
care settings, particularly
those in the private sector.
Nutritional counseling, psy-
chosocial counseling, strate-
gies to modify smoking and
other health-compromising behaviors, and related services shouIc! be pro-
vided directly or through a well-organizecl referral system. In adclition, care
should be providecT in a comfortable atmosphere that underscores the im-
portance of two-way communication patients should receive full answers
to questions about their pregnancies anct should be encouraged to report
relevant symptoms or problems.
At_
- __ ~
__
__
__ -
__-
Prenatal Care for Women at
High Risk of Preterm Delivery
Information on the causes of Tow birthweight and the risk factors associ-
atecl with it has led to the development of several innovative programs
designee! to prevent preterm delivery. Those described in the committee's
report include the March of Dimes Birth Defects Foundation's Multicenter
Prevention of Preterm Delivery Program, which originated at the University
of California at San Francisco; the I os Angeles Prematurity Prevention
Program, implemented in selected health centers that provide prenatal care
for the Harbor-UCLA Medical Center; and the French Prematurity Preven-
tion Program, which started in the early 1970s in Haguenau, France.
Preliminary data from these and other programs suggest several enrich-
ments to basic prenatal care that may increase the likelihood) of full-term
births to women at high risk of preterm delivery:
· repeated risk assessments;
· expanded patient education; and
· increased provider education.
A woman who is at higher than average risk of preterm labor may benefit
from repeated risk assessment as her pregnancy proceeds. In particular,
women who have been defined as high risk because of a previous preterm
OCR for page 30
30
birth or mid-pregnancy loss may require additional cervical assessments in
the second half of pregnancy to check for early signs of dilatation or efface-
ment. The committee is aware that the value and risks of repeated pelvic
examinations in later pregnancy have not been clearly assessed.
Women at elevated risk of preterm delivery should also be offered special
education about the factors associated with prematurity; the importance of
early detection of the symptons of preterm labor/ such as bleeding and
periodic contractions; how to detect mild uterine contractions and how to
differentiate normal contractions that often occur throughout pregnancy
from those signaling early labor; and what to do when the signs and symp-
toms of preterm labor appear, including how to contact an obstetric care
provider for consultation and help. Efforts to arrest preterm labor (such as
use of tocolytic drugs, clescribed below) hinge on its early detection and
prompt management.
High-risk women also should be taught to identify and lessen events in
their daily lives, such as physical stress and strenuous exercise, that can
trigger uterine contractions, which in turn might lead to preterm labor. The
research data supporting such advice are still tentative, but common sense
and clinical judgment support such caution.
To complement patient education, provider education should include
increased emphasis on the importance of being receptive to patients' com-
plaints, some of which may indicate early signs of preterm labor; the uses of
hospitalization for women with suspected preterm labor; and the various
approaches available for arresting true preterm labor, such as tocolysis.
Tocolysis involves the use of specific drugs to inhibit preterm labor. The
one such agent licensed for use in the United States is ritodrine hydrochIor-
ide. Widespread experience with tocolysis indicates that it can be beneficial
in some individual cases of threatened preterm labor, but that the current
generation of tocolytic drugs does not offer a long-term solution to the
problem of prematurity. Some patients with preterm labor have medical or
obstetric complications that caution against the use of tocolytic drugs, and in
~ ~ , ~
.. .. . 1. ~ · .1 ~ . · . . r .1 .1 ~ .
some situations Delivery may ne in the nest interests or tne mother or fetus.
Important side effects can follow the use of tocolytic agents; rarely, complica-
tions may be life-threatening or even fatal.
The number of cases in which tocolytic intervention is successful would
probably increase if patients and providers were better informed about the
early signs and symptoms of preterm labor, the vital importance of early
diagnosis, and the appropriate use of tocolytic drugs. Currently, only about
one-third of pregnant patients who arrive at the hospital in preterm labor are
suitable candidates for this form of therapy.
Prenatal Care for Women at
High Risk of Intrauterine Growth Retardation
Many of the risk factors linked to preterm labor also are associated with
lUGR; thus, some aspects of prenatal care that help to avoid one type of low
birthweight also may help prevent the other. For example, careful risk
assessment is as important for lUGR detection and treatment as it is for
prevention of prematurity.
Unfortunately, the data available to suggest new clinical directions for
OCR for page 31
31
TUGR reduction are more limited than those for preterm delivery. The
literature suggests simply that clinicians caring for pregnant women at
elevated risk of JUGR should place extra emphasis on:
· reduction of behavioral risks such as smoking and alcohol use;
· nutritional surveillance and counseling-maternal preconception
weight and weight gain during pregnancy, especially during the third
trimester, are important determinants of birthweight; and
· early diagnosis and effective management of JUGR through accurate
assessment of gestational age ancT fetal growth anc! maturity; ultrasonogra-
phy can help in meeting such goals.
Programs Complementary to Prenatal Care
Because many of the risks associated with low birthweight have a be-
havioral basis, the committee examined selected interventions designed to
reduce these risks, including smoking reduction strategies and nutritional
intervention programs such as the Special Supplemental Food Program for
Women, Infants and Children (WIC). The committee also evaluated stress
and fatigue abatement approaches, although the evidence that these factors
contribute to low birthweight is controversial. The interventions reviewed
are not, strictly speaking, components of prenatal care, but they should be
adjuncts to more routine prenatal services.
Smoking Reduction
The committee urges that efforts to help women stop or reduce smoking in
pregnancy become a major concern of obstetric care providers. About20 to 25
percent of women who smoke at the beginning of pregnancy quit on their
own at some time during the 9 months. Controlled studies suggest that
aggressive intervention programs can encourage an to an n~rr~ntmor~ to
stop. 19
Several themes derived from the literature on smoking intervention pro-
grams can aid practitioners in establishing effective strategies:
· counseling by a woman's physician or other primary clinician appears to
be among the most effective intervention strategies for the pregnant
smoker group counseling appears to be less effective;
1 -of a- --r -~ ~~ i--
· social support appears to be a critical factor in changing smoking
behavior spouses or partners anc} other family members should be in-
volved in intervention efforts;
· smoking reduction deserves high priority, but prenatal care providers
should be reasonable in their expectations of the pregnant woman she is
probably being asked to make many changes in her life at a time when she
may be unusually tired and anxious about a range of sexual and social
changes associated with pregnancy and planning for a new baby;
· the mass media can play a motivating and reinforcing role in encourag-
ing changes in smoking habits, but are probably insufficient as the sole
approach. Cigarette labels that explicitly warn of the dangers of smoking
during pregnancy should supplement other public information strategies;
and
OCR for page 32
32
· research on smoking and pregnancy should receive high priority
important topics include how to structure interventions to reach specific
high-risk groups, the motivations of women who do stop successfully during
pregnancy, the role of social supports such as the spouse, and how to
encourage continuation of nonsmoking behavior after delivery.
Nutritional Intervention: WIC
The data on nutrition and pregnancy outcome support the view that
nutritional assessment and services should be major components of high-
quality prenatal care, especially for women at elevated risk of JUGR. Accord-
ingly, the committee examined the value of the Special Supplemental Food
Program for Women, Infants and Children (WIC), which provides one of the
principal data sets demonstrating the importance of nutrition to birthweight
and represents a major public investment in the nutritional well-being of
women and children. WIC is a three-part intervention program involving
supplemental food, nutritional counseling, and close ties to prenatal services
for nutritionally and financially high-risk women. Evaluation studies have
shown that WTC participation is associated with improved pregnancy out-
come, including increased birthweight among babies of participating
women.20 21 The results also seem to indicate that longer periods of partici-
pation in the program during pregnancy (i.e., more than 6 months) are
associated with greater weight gains.21
Based on such studies and others reviewed in the main report, the commit-
tee recommends that nutritional supplementation programs such as WIC be
part of a comprehensive strategy to reduce the incidence of low birthweight
among high-risk women and that such programs be closely linked to prena-
tal care.
Stress and Fatigue Reduction
A variety of approaches have been organized to reduce the amount of
stress experienced by pregnant women. Some are concerned primarily with
physical stress and fatigue, others more with psychosocial and emotional
stress.
The prematurity prevention program in France, mentioned earlier,
emphasizes reduction in physical stress for women with several risk factors
(especially a history of preterm delivery, incompetent cervix, or a particularly
strenuous life-style). These women may be advised to take a leave of absence
from their jobs or get additional help at home.
The prematurity prevention program at the University of California at San
Francisco addresses psychosocial and physical stresses simultaneously.
Through a continuing education program, nurses are taught to recognize
1 ~ O ~ O
excessive fatigue or anxiety in their maternity patients and to help the
women find solutions to their problems. High-risk patients also receive
psychological support during pregnancy from a member of the "Preterm
T abor Support Group," which consists of other women who have experi-
enced preterm labor.
Another potentially important stress reducing intervention is maternity
leave. The patchwork arrangement in this country of sick leave, disability
OCR for page 33
33
leave, leave without pay, and other leave categories is not adequate to
provide job security for pregnant women and new mothers who participate
in the labor force. The committee recognizes that revision of maternity
policies is a complicated issue, but suggests that more adequate maternity
leave, particularly for certain high-risk women, could contribute to a reduc-
tion in low birthweight, among other benefits. At a minimum, labor unions,
women's groups, and health professionals should explore this issue.
Encouraging Change in Prenatal Care
To encourage the provision of improved, more flexible prenatal services
t-~ Id; ~_~ ~ l ^ Ilk r [ ~+. . ~] 1 ~1 ~1 _ _ ( 1 _ _ _ 1_ · ~ 1 · ~. . ~1
1 ~
al any But wull`~l aL IllgI! rick or low oIrlnWel~nt tile rommitt~P rP~m-
mends four specific strategies:
Tl~ ~ I: ~ _ 1 ~ ~ _ _ L_ _ _ I 1_ _ d
~^ ~-^ ~-^4b~ ~ ~- ~11 Lll L1 ~ L= ~1 ~11 ~
- ~= ~ ones Nat represent the principal maternity care
providers should carefully review the suggestions made by the committee
regarding prenatal care to determine whether their general guidelines for
clinical practice should be revised and enriched accordingly.
· The Division of Maternal and Child Health (DMCH), in concert with
both consumer and professional groups concerned with prenatal care,
should define a model of services to be used in publicly financed facilities that
provide care to pregnant women. This model should be updated and revised
frequently to incorporate new knowledge and experience, and should not be
used in a way that discourages research on improved approaches to prenatal
care.
- The professional societies of the major maternity care providers should
undertake programs to educate their members about the prenatal care issues
highlighted by the committee. Suggestions for continuing education strate-
gies are outlined in the complete report.
· Third-party reimbursement policies should reflect the common need of
1~: ~1 ~i: _ 1 ~ _ _ _ · . · . .
~ An,, ..^ .~ ~ . ~ .~ ~ ~ en,
nlgn-rlsK women tor more intensive prenatal services, the importance of
prenatal care being tailored to the needs of individual women and thus
variable in its content, the value of counseling and education to reduce
behavioral risks such as smoking, and the importance of ancillary services
such as transportation to health care facilities. The federal model of prenatal
care should emphasize these themes; and labor unions, businesses, and
other organizations should incorporate them into negotiations over health
insurance benefits.
Research Needs
~, ~ ~ ~ _ An. . ~ .
Major progress in reducing low birthweight will require a far more soph-
ishcated understanding of prenatal care content than now exists. Research
on the content of prenatal care should be a high funding priority for founda-
hons, public agencies, and institutions concerned with improving maternal
and child health. This research should focus on three major areas: (~) descrip-
tion and analysis of the current composition of prenatal care, (2) assessment
of the efficacy and safety of numerous individual components of prenatal
care, and (3) evaluation of certain well-defined combinations of prenatal care
interventions designed to meet the widely varied needs and risks among
pregnant women.
OCR for page 34
34
A....
....
................
................
Current Prenatal Care
...
........
..........
The Assistant Secretary for Health should take the lead in organizing
activities to increase our knowledge of current prenatal care practices. Exist-
ing surveys conducted by the National Center for Health Statistics could
include a special emphasis on prenatal care content. Consumer experience
with prenatal care should be analyzed and the professional societies of the
major maternity care providers should be consulted about ways to survey
their members regarding various content issues. in some instances, direct
studies of provider practices may be necessary.
Individual Components of Care
During its study, the committee compiled a long list of research topics
involving specific interventions in prenatal care. They are listed in the full
report and span both clinical topics and environmentaLbehavioral topics.
Combinations of Interventions
Both public and private institutions should support studies to assess the
effectiveness of well-defined combinations of prenatal interventions in
reducing low birthweight and improving infant health generally. In particu-
lar, these studies should assess the merits of different prenatal care strategies
for women at elevatect risk of prematurity or lUGR.
Too often, research on prenatal care has been oriented toward the broad
question of whether it improves pregnancy outcome. The appropriate goal
now is to identify the components and combinations of prenatal services that
are effective in reducing specific risks for well-defined groups of women.
Representative terms from entire chapter:
preterm labor
