Infant Mortality: Is Prenatal Care the Answer?

267 Guest editorial INFANT MORTALITY: IS PRENATAL CARE THE ANSWER? ASHLEY COOPLAND, M.D., M.P.H. Chief, Perinatal & Womens ' Health Services Department of Public Health Commonwealth of Massachusetts 150 Tremont Street Boston 02111 Prenatal care is widely thought to be the "cure" for the unacceptably high infant mortality rate in the United States. However, while prenatal care may achieve some reduction in these extremely high rates, it is probable that the factors that contribute to infant mortality (stress, malnutrition, risk-associated behaviors, depression, etc.) are the same factors that cause women to delay or forego prenatal care. In other words, behavior and lifestyle may be more important than prenatal care in reducing infant mortality. Improving the use of prenatal care would undoubtedly have some positive effect on our high infant mortality rates. Prenatal care would permit the application of both specific and non-specific interventions. Examples of the former include identification and treatment of Rh isoimmunization, identification and early delivery in cases of intrauterine growth retardation, and the careful management of diabetes. Non-specific measures include nutritional advice and social service assistance. Prenatal care also offers an unparalleled opportunity to provide health education, which should include parenting instruction and contraceptive advice. Appropriate prenatal care consists largely of education; the actual medical component is of lesser importance. But providingbetter prenatal care, inand of itself,falls short of addressing the larger issues responsible for infant mortality. Many of these issues are intertwined with poverty. Access to prenatal care is seriously limited for many women living in poverty, as will be discussed later. Poverty is also associated with increased rates of smoking, drug abuse, sexually transmitted disease, and other harmful factors, all of which can have negative effects on the outcome of a pregnancy and the subsequent development of an infant. While the elimination of poverty would cause the greatest improvement Journal of Health Care for the Poor and Underserved, Vol. 1, No. 3, Winter 1990 268____________Prenatal Care and Infant Mortality___________________ in infant mortality, such is not a realistic goal in the foreseeable future. But other measures, if adopted, could greatly help. For example, recent efforts to reassess traditional approaches to prenatal care have resulted in a variety of innovations. One U.S. Department of Health and Human Services commission1 has recommended, among other things, emphasis on the preconceptional visit and a reduced frequency of visits for the majority of patients whose pregnancies are normal. Since the probability of preconceptional visits in a disadvantaged population is low, the first prenatal visit is of critical importance. A thorough history and physical examination are essential. Necessary laboratory studies must be performed, and mostimportant of all, a risk status is assigned. The risk status is based on medical, obstetrical, and social factors and is updated at each visit. Indeed, the risk status will determine the interval between visits, as well as the level of provider sophistication the patient requires. Routine prenatal care may be delivered (many feel best delivered) by a midwife. Suitably experienced family physicians may provide prenatal care and attend to any minor coexisting illnesses. For patients with obstetrical complications, consultation with or continuing care by a perinatologist/obstetrician is indicated . In the general population, such highly specialized care is probably necessary in fewer than 10 percent of cases. Among the medically underserved, such care might be necessary in perhaps twice that number. Even so, the great majority of cases would be handled by midwives and family practitioners. Other measures deal with opening channels of access. Today the popular press and medical literature alike are replete with discussions of barriers to prenatal care. To many, the term "barrier" is synonymous with "cost." The assumption is that if funding is provided, access to medical care in general, and prenatal care in particular, will be assured. This view, prevalent among legislators, ignores the other, very real barriers that cause pregnant women not to avail themselves of prenatal care. Some women simply do not understand the importance of early and adequate prenatal care. Immigrants, refugees, or other patients unfamiliar with English or lacking basic education often do not understand medical procedures or what is expected of them as patients. Frequently the barrier is fear, a paralyzing...