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1. Who Obtains Insufficient Prenatal Care?
Pages 26-53

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From page 26...
... Women in certain sociodemographic groups and in certain geographic areas are significantly less likely than others to secure care, and in recent years, use of prenatal care has actually declined among some groups. Relying primarily on national vital statistics, this chapter presents data on these correlates and trends, focusing in particular on women who receive little or no care, because such minimal care is strongly associated with poor pregnancy outcomes.
From page 27...
... Most studies of the effectiveness of medical care examine provider actions for example, did the physician take an adequate history, order the appropriate tests, and conduct the right procedures? By contrast, studies of the role of prenatal care in pregnancy outcome usually examine consumer actions—for example, ctid the pregnant woman initiate care early, and how many visits did she make?
From page 28...
... The questionable accuracy of birth certificates is substantiated by a study of the 1972 National Natality Survey, in which the number of prenatal visits listed on birth certificates was compared with survey data. Perfect agreement was found in only 16 percent of the cases.6 In another study, Land and Vaughan reviewed Missouri birth certificate data for 1980 and found that hospitals that obtained information on prenatal care exclusively from the mother reported earlier prenatal care and more visits than those using the prenatal record only or a combination of the prenatal record and information from the mother.7 Another limitation of birth certificate data is that not all states request information about ethnic origin or the mother's marital status.*
From page 29...
... A final point: Where vital statistics data are used in this chapter, the data technically refer to infants rather than mothers, because each record is based on an individual birth certificate. However, since multiple births are relatively infrequent (21 per 1,000 live births in 1985)
From page 30...
... Racial and Ethnic Subgroups Racial disparities in the use of prenatal care are substantial (Table 1.1~. In 1985, black women were far less likely than white women to begin care early and twice as likely to receive late or no care.
From page 31...
... The higher rates of late or no care among black women are probably due to the greater concentration in this population of several risk factors associated with insufficient prenatal care: limited education, being unmarried (in 1985, 11 percent of white births were to unmarried women versus 57 percent of black births) , and, in particular, poverty.
From page 32...
... were to mothers who had been born in the United States.~° Generally, Hispanic mothers are substantially less likely than nonHispanic white mothers to begin prenatal care early and are three times as likely to obtain late or no care. Moreover, as Table 1.3 shows, Hispanic mothers as a group are more likely than non-Hispanic black mothers to
From page 33...
... In that same year, Chinese, Japanese, and Filipino women exhibited particularly high rates of participation in care and were less likely than white women to obtain late or no care; Hawaiian women and other subgroups of women in this category (including Indian, Cambodian, Laotian, Vietnamese, Korean, and other Asian or Pacific Islander women) placed between white and black women in the late or no-care category.
From page 34...
... Using 1980 National Natality Survey data, one study found that mothers under age 20 were nearly twice as likely to have inadequate care as mothers age 20 to 24 (16.4 and 8.4 percent, respectively) .~5 Older mothers, much as teenagers, tend to delay entry into prenatal care (Table 1.1~.
From page 35...
... In both 1984 and 198S, 79 percent of all mothers had completed at least 12 years of schooling—82 percent of white mothers, 68 percent of black mothers. In 1984, more than twice the proportion of Native American mothers (American Indians and Native Alaskans)
From page 36...
... completed high school.~9 For mothers of Hispanic origin, 21 states (not including California and Texas) reported in 1984 on educational attainment; overall, 4S percent of Hispanic mothers giving birth in that year had not completed at least 12 years of school, with subgroup proportions ranging from S9 percent for Mexican mothers to 22 percent for Cuban mothers.20 Birth Order Obtaining late or no prenatal care is also associated with birth order.
From page 37...
... has concluded that the different age distribution of white and black women at the time of first birth explains these minor variations.22 Marital Status Pregnant women who are married are more likely to obtain sufficient prenatal care than pregnant women who are not married (Table 1.79. This relationship holds true among women within the same racial or ethnic group and with similar levels of education.23 Unmarried mothers are more than three times as likely as married mothers to obtain late or no prenatal TABLE 1.7 Percentage of Babies Born to Women Obtaining Late or No Care, by Race and Marital Status, United States, 1975, 1980, ant]
From page 38...
... in 198S.24 In that year, 12 percent of non-Hispanic white births were to unmarried women, compared with 61 percent of non-Hispanic black births and 23 percent of Hispanic births. The range among the latter group, however, is striking: S1 percent of Puerto Rican births were to unmarried women versus 26 percent of Mexican births.25 The differential between married and unmarried women's timing of entry into prenatal care lessens somewhat with increasing age; however, at any age unmarried women are much more likely than married women to obtain late or no care.26 With regard to the relationship among marital status, age, and use of prenatal care, Ventura and Hendershot analyzed 1980 National Natality Survey data and found that"teenage mothers began prenatal care earlier if they were married at conception than if they were not .
From page 39...
... Thirty-eight percent of women with annual incomes of less than $10,000 obtained adequate prenatal care; 64 percent of women with annual incomes between $10,000 and $20,000 were in the adequate care category; and for women with annual incomes between $40,000 and $SO,000, the percentage climbed to 88.32 Given that one-third of all U.S. births are to women with incomes less than lSO percent of the federal poverty level,33 the consistent correlation of low income with insufficient prenatal care is of major importance and forms the basis of many recommendations that appear later in this report.
From page 40...
... <150 100 3.7 15~249 22 1.1 2250 47 1.3 Total 169 2.0 aAn income of 150 percent of the poverty level or more is considered nonpoor. bRisk of 1.0 for the reference group represents a level of inadequate care of 2 percent (with inadequate care defined as care in the third trimester or no care)
From page 41...
... GEOGRAPHIC POCKETS OF NEED Insufficient prenatal care is concentrated in certain geographic areas, just as it is in certain demographic groups. Analyses of 198S vital statistics data conducted by the Children's Defense Fund found wide disparities among states in the percentage of infants born to women obtaining late or no care (Table 1.10 and Figure 1.1 )
From page 42...
... 42 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 1.10 Percentage of Babies Born to Women Obtaining Late or No Care, All Races, All States and the District of Columbia, 1969, 1975, 1979, and 1985 State 1985a 1979a 1975b l969b Alabama 6.2 6.3 Alaska 4.4 S 1 Arizona 7.7 8.1 13.S 20.9 Arkansas 7.4 6.3 California 5.4 4.9 6.0 7.2 Colorado 5.4 4.7 5.2 Connecticut 3.0 2.3 2.6 Delaware 4.3 4.5 3.9 District of Columbia 11.4 8.0 14.8 22.S Florida 9.0 7.0 7.8 Georgia 5.3 6.0 7.5 Hawaii S
From page 43...
... in New York in 198S was roughly three times as likely as a woman in Michigan or Connecticut to obtain late or no care, and a nonwhite woman in New Mexico or New York was three times as likely as a nonwhite woman in Massachusetts to obtain late or no prenatal care. The analyses also show that states with low percentages of mothers obtaining early care also tend to have high percentages of mothers obtaining late or no prenatal care.
From page 44...
... These maps rheas that rural as wed as urban areas exhibit pocked of insufficient prenatal care. Figures 1.4 and 1.5 present a 1985 geographic profile of late or no registration in prenatal care for the District of Columbia and New Haven, Connecticut.
From page 45...
... nasality statistics published by the National Center for Health Statistics,43 make possible an
From page 46...
... 46 it, ~ ~ ~ ~- ~ ~ ._ Cal Cal ~ ~ o ~ :z Cal .
From page 47...
... In fact, 198S rates of late or no prenatal care for black women are about the same as those recorded in 1976; improvements in the interim have, in effect, been erased. An analysis of trends in the use of prenatal care between 1970 and 1983 found that early enrollment for black mothers in 1982 was 3.6 percentage points below what it would have been if the 1976 to 1980 trend had continued, and 10.8 percentage points below the expected level based on the 1970 to 197S trend.44
From page 48...
... All 37 reporting states and the District of Columbia showed smaller percentages of women obtaining late or no care in 197S, as compared to 1969. Most states demonstrated decreases of \ y~ ~~\~ :'=: Percentage of Births c 11.0 [I 11.0to15.0 >15.0 L_ FIGURE 1.5 Percentage of births to women obtaining late or no prenatal care, New Haven, Connecticut, by neighborhood, all races, 1982-198S.
From page 49...
... Between 1979 and 1985, the increase in the percentage of women obtaining late or no care evidenced in national statistics was mirrored in states from every region of the country. For example, although the number of women beginning care late or not at all in the District of Columbia dropped by 65 percent between 1969 and 1979, the number increased 43 percent between 1979 and 198S.
From page 50...
... Other reasons include the cutbacks in Medicaid eligibility in the early 1980s and the declining proportion of the poor covered by Medicaid; the increasing proportion of births to unmarried women and the growth in the number of households headed by single women; and the increasingly limited capacity of the health care systems relied on by Tow-income women for prenatal care, caused by funding restrictions and the malpractice squeeze, which is shrinking the pool of obstetric care providers. Many of these issues are discussed in Chapter 2.
From page 51...
... SUMMARY Several interrelated demographic factors put women at risk for insufficient prenatal care: being in a racial or ethnic minority group (especially American Indian, black, and Hispanic) , being under 20 (particularly, under 15)
From page 52...
... 16. National Center for Health Statistics, Division of Vital Statistics.
From page 53...
... 31. Unpublished data from the 1982 National Survey of Family Growth, provided by the Family Growth Statistics Branch, Division of Vital Statistics, National Center for Health Statistics, U.S.


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