Preventing Low Birthweight (1985) / Chapter Skim
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8. Improving the Content of Prenatal Care
8. Improving the Content of Prenatal Care
Pages 175-201
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From page 175... ...
2. Interventions closely associated with prenatal services can help to reduce low birthweight, particularly programs aimed at smoking reduction and better nutrition.
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From page 176... ...
At present, prenatal care seems particularly oriented toward the prevention, detection, and treatment of problems that are manifested in the third trimester, particularly preeclampsia -- thus the emphasis on blood pressure monitoring, screening for proteinuria, attention to possible edema, and increased frequency of prenatal visits toward the end of pregnancy. By contrast, the goal of preventing low birthweight r equires additional attention dur ing the first and second tr imesters especially to screening, diagnosis, and treatment, as early as pass ible, of conditions that predispose to preterm labor or IUGR, such as smoking and poor nub' tional status.
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From page 177... ...
Infections, too, may go unrecognized and untreated during pregnancy. For example, some data point to asymptomatic bacteriuria as a potential cause of low birthweight (Chapter 2~' yet in many prenatal settings, no attention to detecting asymptomatic bacteriuria occurs.
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From page 178... ...
In particular, ultrasonography can help to date pregnancies accurately and to monitor fetal growth and development. It has therefore become an important component of prenatal care directed at preventing low birthweight and other poor outcomes.
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From page 179... ...
~ 3 Another limitation of these classes is that they do not reach all portions of society equally. Numerous studies have shown that participants in childbirth education courses tend to be married women who are older, better educated, of a higher socioeconomic group, more likely to hold good jobs, and more positive about their pregnancies than are the women who do not per ticipate.~ Accordingly, efforts should be made to enroll in these classes more pregnant women from those groups that often fail to take advantage of them, particularly because many such women are at high risk of low birthweight on the basis of social, economic, and behavioral factors.
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From page 180... ...
1. Risk Assessment A woman who is at higher than average risk of preterm labor requires repeated risk assessment as her pregnancy proceeds.
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From page 181... ...
Efforts to arrest preterm labor can hinge on its early detection and prompt management. Higher isk 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.
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From page 182... ...
Side-effects produced by tocolytic agents include decreased peripheral resistance, decreased blood pressure, tachycardia, and frequently, palpitation and chest pain; rarely, pulmonary edema may be life threatening or even fatally 20 Current exper fence with tocolysis, which is now extensive, suggests several conclus ions . First, In individual cases of threatened preterm labor, tocolytic therapy can often be effective, though not always.
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From page 183... ...
As noted earlier, ultrasonography can help to establish gestational age when uterine size-date discrepancies are noted. Programs Complementary to Prenatal Care Because many of the risks associated with low birthweight have a behavioral basis, the committee examined selected interventions intended to reduce behavioral risks, including smoking reduction programs for pregnant women and nutrition intervention programs such as the Special Supplemental Food Program for Women, Infants and Children (WIC)
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From page 184... ...
Smoking Reduction Programs Several types of programs have been developed in var ~ ous settings to help pregnant women stop or reduce their smoking habit. Most are based on the finding that pregnancy alone provides a strong incentive to stop smoking.
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From page 185... ...
For others, concerns about the health consequences of smoking dur ing pregnancy may provide the impetus for attempting to quit initially, but may not be sufficiently strong to maintain cessation over the entire course of pregnancy. Another type of intervention program recognizes the importance of involving the woman's partner in smoking cessation programs .2 9 Based on the understanding that it is more difficult for a woman to stop smoking if other members of the household smoke, Wilner et al.
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From page 186... ...
In sum, there is no question that smoking reduction or cessation is possible In pregnancy and that it has the potential to play a major role In any overall strategy to reduce low birthweight. Accordingly:
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From page 187... ...
3 0 Evaluation studies show that prenatal participation in the WIC program Is associated with improved pregnancy outcomes.30~33 Wile all of the studies have some methodologic problems -- WIC evaluations are particularly hindered by difficulties in obtaining an appropriate comparison population and in securing a representative WIC sa'eple -- the similarity of their results supports the overall conclusion that the WIC program provides positive benefits to nutritionally and financially h~gh-risk pregnant women. Of particular relevance to this report is the decrease In low birthweight incidence associated with WIC participation.
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From page 188... ...
Caan compared the birth outcomes of a group of women who per tic~pated in WIC during a first pregnancy, continued to receive WIC in the interpregnancy period, and remained in the program during a second pregnancy, to a group of women who also participated in WIC during both pregnancies but received very little supplementation in the interpregnancy period. The difference mean birthweight adjusted for gestational age between the two groups was 160 grams.3 ~ WIC is not the only prenatal nutrition intervention program that has been associated with improvement in low birthweight status.
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From page 189... ...
Stress and Fatigue Alleviation Even though the evidence associating stress with low birthweight is of uneven quality, several programs have tried to reduce the levels of stress experienced by pregnant women In an effort to improve pregnancy outcome. Some are concerned primarily with physical stress and fatigue, others more with psychosoc i al and emotional stress .
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From page 190... ...
Encouraging Change in Prenatal Services To encourage the provision of improved, more flexible prenatal services, particularly for women at elevated risk of low birthweight,
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From page 191... ...
These organizations include the American College of Obstetricans and Gynecologists, the American College of Nurse-Midwives, the American Academy of Family Practice, the Nurses Association of the American College of Obstetricians and Gynecologists, the various state level Perinatal Associations, and the American Public Health Association (particularly its Public Health Nursing section ~ . Second, there is a role for federal leadership in enhancing the capacity of prenatal care to reduce low birthweight.
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From page 192... ...
This program, which involves meetings between specially trained health professionals based in medical schools and community clinicians, demonstrates the leadership role that medical schools can play in reducing the incidence of low birthweight.4 7 · County medical society gatherings and meetings of national professional organizations are important sources of information for their members. At the scientific meetings of such groups, the topic of how to strengthen the capacity of prenatal care to reduce low birthweight should be given increased emphasis.
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From page 193... ...
In Chapter 6, the evidence that prenatal care decreases the incidence of low birthweight is presented. AS noted in that section, however, prenatal care" is not carefully defined or uniformly practiced.
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From page 194... ...
For example, ACOG periodically publishes Standards for Obstetric-Gynecologic Services, which outlines both the recommended content and scheduling of prenatal cared These standards are a codification of current understanding of important prenatal problems and their management, as are the Guidelines for Perinatal Care developed jointly by ACOG and the American Academy of Pediatrics .2 Adequate data do not exist, however, on the extent to which these standards are followed In various practice settings. Information is available regarding the brief amount of time obstetricians typically spend with patients in routine prenatal ViSitS48 and about the schedule of prenatal visits followed by some groups of women.~9 However, the extent to which prenatal care providers follow specific ACOG suggestions regarding formalized risk assessment, nutritional status assessment, prenatal education, efforts to reduce smoking In pregnant patients, and related interventions is unknown.
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From page 195... ...
; · evaluating the efficacy and safety of various prenatal progestational agents; and · assessing the effect on pregnancy outcome of treating a range of genitourinary tract infections and organisms. Behavioral and Environmental Topics · determining the best techniques of educating pregnant women (particularly h~gh-risk women)
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From page 196... ...
Others are more accurately descr ibed as Community based, ~ often involving larger numbers of women and addressing issues of access , f intoning, and linkages among care providers, as well as prenatal care content . Such pro jects include, for example, the Better Babies project in Washington, D.C.; the Florida and North Carolina prematurity prevention activities; the efforts in South Carolina directed at low birthweight prevention; and the program being planned by the Department of Obstetrics and Gynecology of the Albert Einstein College of Medicine in New York.
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From page 197... ...
A variety of research programs should be developed in both the public and private sectors to increase the ability of prenatal care to reduce low birthweight. Research efforts should focus on three areas: analyses of current prenatal care practices in multiple settings; assessments of the efficacy of individual components of prenatal care; and evaluations of combinations of prenatal interventions specif ically designed to meet the widely varying needs of pregnant women.
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From page 198... ...
U.S. General Accounting Office: Better Management and More Resources Needed to Strengthen Federal Efforts to Improve Pregnancy Outcome.
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From page 199... ...
24. Committee to Study the Prevention of Low Birthweight: Efforts to change smoking and drinking behavior in pregnant women.
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From page 200... ...
44. Herron MA and Dulock BL: Preterm Labor: A Staff Development Program in Perinatal Nursing Care.
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From page 201... ...
48. National Center for Health Statistics: Office Visits by Women: The National Ambulatory Medical Care Survey.
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