Running Head: EFFECTS OF PRENATAL CARE 1

Effects of Prenatal Care on Newborn Health Throughout the First Year of Life

Madison Evans, Michael Guterwill, Kimberly Masone, Alexandra Watkins, Ashley Wolanzyk

Youngstown State University

Abstract

The purpose of this research is to examine the relationship between the health of the newborn

that has received adequate prenatal care, as compared to the health of the newborn that has

received minimal or inadequate prenatal care. The correlation between prenatal care and the

following aspects were analyzed: infant mortality, number of well child visits, screenings and

vaccinations, infant injury, low and very low birth weight, and long-term outcomes throughout

the first year of life. Data was acquired from ten sources including academic journals and

quantitative studies. This research shows considerable evidence that adequate prenatal care

decreases the likelihood of a pregnancy resulting in a low or very low birth weight infant, as well

as infant mortality. There is evidence showing that adequate prenatal care increases number of

well child visits, screenings, and vaccinations acquired. Findings here suggest that prenatal care

does not have any benefit on decreasing infant injury after birth. Overall, the research completed

showed overwhelming benefits for prenatal care by lowering both infant mortality and low-birth

weight occurrences.

Keywords: prenatal care, infant health, low birth weight, infant mortality
EFFECTS OF PRENATAL CARE 3

ASHLEY

Effects of Prenatal Care on Newborn Health Throughout the First Year of Life

It has been well documented that there are a multitude of factors that can contribute to the

health and wellbeing of a newborn. It can be argued that prenatal care is one of these factors

being of utmost importance. Prenatal care (PNC) is “pre-delivery care [that] usually consists of

medical screening, physical and ultrasound exams, education and counseling” (Hawley et al.,

2013, p. 2284). Regular exams and checkups during pregnancy help doctors and nurses monitor

maternal and fetal health to promote a successful and healthy pregnancy.

According to VanderWeele, Lauderdale, and Lantos (2013), “use of prenatal care, both

the proportion of women receiving the recommended number of visits and the average number of

visits, has increased substantially” (p. 435). While this is remarkably reassuring to hear, there are

still complications that exist during pregnancy, despite the undeniable rise in prenatal care. Still,

not all expecting mothers receive what is considered an adequate amount of prenatal care during

their pregnancies. This is a significant issue being addressed by the nursing profession as nurses

strive to provide the best medical care for all patients. Nurses seek to encourage health and

wellness in obstetric patients and newborns.

Adequate prenatal care scheduling is not definitive. There are varying recommendations

as to what constitutes an adequate amount of care during pregnancy. For one, the World Health

Organization (WHO) recommends a minimum of four prenatal visits starting early in pregnancy

(Liu et al., 2017). On the contrary, the American College of Obstetricians and Gynecologists put

forth a recommended prenatal visit schedule of “one visit per month for the first six months, two
EFFECTS OF PRENATAL CARE 4

per month in the seventh and eight months and weekly visits from the ninth month onward”

(VanderWeele et al., 2013, p. 436). Substantial and adequate prenatal care increases potential for

a myriad of benefits for both mom and baby, yet the disconnect in this area of the nursing

profession remains. In this report the following research question was addressed: in pregnant

women, how does receiving adequate prenatal care, as compared to not receiving adequate

prenatal care, affect the newborn’s health in regard to infant mortality, well child visits,

screenings, vaccinations, injury, and birth weight, throughout the first year of life?

Literature Review

In order to research this topic in the nursing profession, information was gathered on

current theory and evidence related to prenatal care and its subsequent effects on infant health.

Data was obtained through OhioLINK databases: CINAHL Plus, MEDLINE, ProQuest Nursing

and Allied Health Source, and EBSCOHost. Ten sources were reviewed for data collection

regarding how infant health was affected by prenatal care during pregnancy. Three sources

focused exclusively on prenatal care on infant mortality rates, while five of ten sources explained

effects of prenatal care on infant weight at birth. Infant mortality, well child visits, screenings,

vaccinations, injury, low and very low birth weight, will be discussed.

Infant Mortality MADISON

Infant mortality rate (IMR) is defined as “the number of live born infants dying in the

first year of life per 1000 live births” (Gabbe et al., 2017, p. 1130). With the surge in stressing

the importance of prenatal care, infant mortality rates have been on the decline. Statistics show a

steady increase in the number of premature births and suggest a linkage with the decline in IMR.
EFFECTS OF PRENATAL CARE 5

VanderWeele et al.’s (2013) study found the following: prenatal care dramatically

reduces the risk of infant mortality by increasing the prevalence of medically induced preterm

births. Furthermore, an increase in medically induced premature births was seen from those who

sought an adequate amount of prenatal care. It is theorized that this trend is the result of an

increase in prenatal care visits allowing for early detection and intervention of medical issues.

Infant mortality is associated with medically induced preterm births, however, the relationship

between the two is inverse (VanderWeele et al., 2013). Thereby, with prenatal care being a cause

of detecting medical abnormalities early on, preterm labors are induced more frequently. This

results in better medical care and improved infant outcomes as infant death occurs less

frequently. According to the data collected, this statement holds some validity. In this study, the

childbearing woman with more than recommended number of prenatal visits, as compared to the

childbearing woman with less than recommended prenatal visits, will be least likely to

experience a birth that leads to infant mortality (VanderWeele et al., 2013).

A study conducted by Gabbe et al. (2017) also found that prenatal care is linked to a

decrease in infant mortality. This study implemented a prenatal care and support group,

Moms2B, in an impoverished community in Columbus, Ohio. The reason infant mortality rates

are so important to analyze is because they directly reflect maternal health, infant health, and

overall health of entire communities. The findings of this study were that due to the

implementation of the Moms2B program, infant mortality rates in the neighborhood declined.

The study revealed that in the four years before initiating Moms2B (2007-2010), there were 442

births and six infant deaths giving an IMR of 14.2 per 1000 (Gabbe et al., 2017). In the four
EFFECTS OF PRENATAL CARE 6

years after implementing Moms2B (2011-2014), there were 328 births and only one infant death

giving an IMR of 2.9 per 1000 (Gabbe et al., 2017). Furthermore, the mother of that one infant

was not part of the Moms2B program (Gabbe et al., 2017). This study confirmed yet again that

increased prenatal care decreases infant mortality, while suggesting that lack of prenatal care

contributes to an increased IMR.

In addition to these two studies, a third study was analyzed and further suggested a

relationship between prenatal visits and infant mortality. Swartz, Hainmueller, Lawrence, and

Rodriguez (2017) conducted research on immigrant women and health service utilization during

their pregnancies; findings obtained show a decrease in infant mortality in the first year of life

with adequate prenatal care received (-1.01 reduction in infant mortality/1,000 live births). The

study explains that expanding access to prenatal care influences health outcomes for infants.

Well Child Visits, Screenings, and Vaccinations MICHAEL

Swartz et al.’s (2017) study examined effects of expanding access to prenatal care on

immigrant women aged 12-51 years old and their babies aged 0-1 years in the state of Oregon

from January 1, 2003 to October 1, 2015. The study used prenatal visits, outpatient visits during

pregnancy, ultrasonography, and vaccinations as measurable data reflecting mother health.

Comparisons were made using several markers of infant health care during first year of life

including: number of well child checks, outpatient visits, urgent care or emergency department

visits, standard vaccinations and screenings in first year of life, low birth weight, extremely low

birth weight, preterm birth, and infant death. Those with access to prenatal visits showed

increase in diabetes screening and fetal ultrasounds (Swartz et al., 2017). In response to

receiving adequate care during pregnancy and developing good habits of attending scheduled
EFFECTS OF PRENATAL CARE 7

checkups early on, an overwhelming amount of resulting benefits to infant health were

discovered. Prenatal care was associated with an increased number of well child visits, increased

rates of receiving recommended screenings and vaccines, reduced infant mortality rates, and

reduced rates of extremely low birth weight, once the infant was born (Swartz et al., 2017). It

was concluded that prenatal care expansion programs increased health service utilization and

improved health outcomes for immigrant women and their children.

Infant Injury

Infant injury is commonly seen in the first year of life. A study initiated by Meghea, You,

and Roman (2015) attempted to explain why high-risk first-time moms receiving prenatal care

home visits were more likely to have children sustaining more superficial injuries during the first

two years of life, compared to moms not part of the prenatal home care initiative.

The perceived goal of mothers receiving home care through the Maternal Infant Health

Program (MIHP) was to help decrease rates of infant mortality and injury. MIHP provided

“home-based care coordination, referrals, and risk-specific interventions with the aims of

promoting healthy pregnancies, positive birth outcomes, and healthy infants” (Meghea et al.,

2015, p. 2120). The MIHP focuses on keeping the infant safe by childproofing the home,

promoting safe sleep, and educating the parents. However, the study concluded significant

differences between those who participated in MIHP and those who did not.

Infants whose mothers were participating in MIHP experienced more superficial injuries

such as open wounds and intracranial injuries (Meghea et al., 2015). The MIHP prenatal care

education and patient teaching failed to deliver lower rates of infant injury. This study showed
EFFECTS OF PRENATAL CARE 8

that infants of MIHP participants had an 11.7% rate of injury compared to 10.4% rate of infants

of non-participants (Meghea et al., 2015). Also, it was concluded that prenatal care impacted

number of superficial injury incidents. Infants of MIHP participants were more likely to have a

superficial injury compared with infants of nonparticipants: 4.9% versus 3.9%, respectively

(Meghea et al., 2015). Therefore, prenatal care did not reduce the risk for injury in infants during

their first year of life.

Low and Very Low Birth Weight KIM

Low birth weight (LBW) is relatively common and has been reported as a significant

contributor to mortality perinatally as well as health complications later in life. A child born with

a low birth weight, weighing less than 2500 grams, is at higher risk of developing heart disease,

diabetes, high blood pressure, and obesity later in life (Dai, Mao, Luo, & Shen, 2014). One way

to reduce the occurrence of LBW is by receiving adequate prenatal care. Studies regarding the

effectiveness of prenatal care and reduced incidence of LBW have been ongoing. However,

many of these studies may contain a selection bias regarding the women they chose for the

studies.

A study done by Loftus, Stewart, Hensley, Enquobahrie, and Hawes (2015) attempted to

eliminate this selection bias by creating a longitudinal study saying, “we stratified women on

level of PNC received prior to first birth and assessed the association between PNC and LBW at

second birth” (p. 2628). Using this type of selection eliminated some of the variations between

test subjects by comparing the differences between births from the same women. The study

consisted of two groups: the first of 10,688 women received inadequate PNC during the first
EFFECTS OF PRENATAL CARE 9

pregnancy, while the second of 58,341 women received intermediate or adequate PNC during the

first pregnancy (Loftus et al., 2015). This study was remarkable due to the comparison of

subsequent pregnancies from the same mothers to help distinguish patterns. In the study, 72% of

the first group went on to receive intermediate or adequate PNC before their second birth, while

13% of the second group received inadequate PNC before their second birth (Loftus et al.,

2015). The conclusions suggested that receiving inadequate care during the first pregnancy and

adequate care during the second pregnancy lead to an almost 40% reduction in LBW for the

second infant (Loftus et al., 2015). It was also found that decreasing from adequate PNC during

the first pregnancy to inadequate in the second pregnancy, showed nearly a 60% increase in

LBW for the second pregnancy (Loftus et al., 2015). These findings support the notion that

receiving adequate PNC lowers the risk of an infant being born with a low birth weight.

An important conclusion can be drawn from this study: even if a woman receives

adequate PNC during her first pregnancy, it is still necessary for her to receive adequate PNC

during future pregnancies to reduce LBW risk. This study also examined whether there was a

notable difference in reduction of LBW risk when receiving either intermediate or adequate

PNC. They concluded that there is no additional benefit to receiving either intermediate or

adequate PNC (Loftus et al., 2015). This means that the number of visits required for a pregnant

woman to attend could be lowered without causing increased risk to the infant, however, further

studies should test this new finding.

ALLIE

Very low birth weight (VLBW) is an infant with an even lesser weight than what is

considered low birth weight. For example, an infant weighing less than 1500 grams is the
EFFECTS OF PRENATAL CARE 10

determination factor of a very low birth weight (Xavierus, Alman, Holtz, & Yarber, 2015). Very

low birth weight infants are at greater risk for neurodevelopmental impairment, recurrent

hospitalizations, and chronic medical conditions (Xavierus et al., 2015). In a study by Xavierus

et al. (2015), inadequate prenatal care is viewed as “fewer than five prenatal visits for

pregnancies <37 weeks gestation, fewer than eight visits for pregnancies 37 weeks gestation or

more, or care beginning after the first 4 months of pregnancy” (p. 624). This determination

factor was employed as a tool of measurement in selecting which pregnancies would classify as

resulting VLBW infants. Of the 152,590 birth records reviewed, 10.7% of women did not

receive adequate prenatal care, according to the study’s definition (Xavierus et al., 2015). This

percentage is then examined in terms of demographic data of the women receiving inadequate

prenatal care. Amongst these women, 79% were black, 33.6% were under 20 years of age,

77.9% had completed less than a high school education, 74.9% were on Medicaid, 24.5% were

smokers, and 5.95% gave birth at less than 32 weeks gestation (Xavierus et al., 2015).

Examining demographic data of women who receive inadequate prenatal care in a large, urban

area allows researchers to determine the population most at risk for receiving inadequate prenatal

care, and in turn, a VLBW infant.

Risks for VLBW infants, regardless of adequacy of care, include premature birth (before

37 weeks gestation), African American, maternal age greater than 34, primiparity, gestational

hypertension, and eclampsia (Xavierus et al., 2015). Among the women receiving inadequate

prenatal care, being on Medicaid was protective against VLBW, while smoking was a risk factor

for VLBW (Xavierus et al., 2015). For women receiving adequate prenatal care, smoking was
EFFECTS OF PRENATAL CARE 11

not a risk factor for VLBW, and being on Medicaid was not a protective factor from VLBW

(Xavierus et al., 2015).

Research concluded that “women receiving inadequate prenatal care were more likely to

deliver a VLBW infant than those receiving adequate prenatal care” (Xavierus et al., 2015, p.

628). While it is important to study at risk populations, such as a large urban area like St. Louis,

it may not be applicable to other locations or the United States as a whole. It is also important to

note that intention of becoming pregnant was not indicated by the women, which may have

altered their intent to seek prenatal care (Xavierus et al., 2015). Limitations aside, this study

found significant differences in prenatal care categories.

The results of a study done in one U.S. city do not represent the entire country, however,

results from other geographic locations may be similar. In a study done by Guillory, Lai,

Suminski, and Crawford (2015), it was deduced that “late or no prenatal care was associated with

a 30% increase in LBW” amongst infants studied (p. 585). This study examines the effect of

insurance status on birth weight. It notes that insurance status is associated with initiating

prenatal care and whether the care is adequate or inadequate. Women with private insurance

were more likely to initiate care earlier than those without private insurance (Guillory et al.,

2015).

It is a complex process to determine the association of prenatal care and birth weight

outcomes because there are many scales used to measure prenatal care adequacy. The Adequacy

of Prenatal Care Utilization Index is a two-dimensional scale used to measure timing of initiation

of care and utilization of the care (Guillory et al., 2015). This scale was used in a study that
EFFECTS OF PRENATAL CARE 12

found Caucasian women more likely to receive adequate prenatal care than African American

women. As a result, the chance of having a LBW infant was more common for women who

received inadequate care (Guillory et al., 2015).

CONCLUSION

The purpose of this research was to observe the relationship between the outcome of

health in a newborn who received adequate prenatal care, related to the health of a newborn that

received inadequate prenatal care, and how prenatal care has been shown to directly influence

infant health outcomes. This report reviewed the relationship PNC has on infant mortality rates.

In one study, it was found that the childbearing woman with more than the recommended amount

of prenatal care visits will be least likely to experience a birth that leads to infant mortality

(VanderWeele et al., 2013). Another aspect examined was prenatal visits during pregnancy and

resulting trends in well child visits, screenings, and vaccinations. Adequate prenatal care was

associated with an increased number of well child visits, screenings for potential health

detriments, and receiving recommended vaccines (Swartz et al., 2017). Correlations with infant

injury and prenatal care were shown. A study on the Maternal Infant Health Program (MIHP)

concluded that prenatal care coincides with an increase in infant injuries (Meghea et al., 2015).

Relations between birth weight and prenatal care were reviewed. Research found that having

adequate prenatal care in a first pregnancy and inadequate prenatal care in a second pregnancy

led to drastic increases in LBW for the second pregnancy (Loftus et al., 2015). The trend in this

research shows significant benefits to the infant’s health after the mother receives adequate

prenatal care during pregnancy.

Previous studies have agreed that prenatal care lowers the risk of low birth weight and

increases overall infant health. However, previous studies have not been consistent with what is

considered adequate or inadequate care, nor examined multiple health outcomes for infants born.

Most research on the relationship of PNC and infant health focus on single health outcomes

rather than a multitude of outcomes. Limitations to our research includes potential selection bias

in groups chosen for studies, inconsistency in methods of data collection, and impact of outside

variables (other than prenatal care) on results of studies.

Resources

Dai, L., Mao, Y., Luo, X., & Shen, Y. (2014). Prenatal care in combination with maternal

educational level has a synergetic effect on the risk of neonatal low birth weight: New

findings in a retrospective cohort study in Kunshan City, China. Plos ONE, 9(11), 1-13.

doi:10.1371/journal.pone.0113377

Gabbe, P. T., Reno, R., Clutter, C., Schottke, T. F., Price, T., Calhoun, K., . . . Lynch, C. D.

(2017). Improving maternal and infant child health outcomes with community-

based pregnancy support groups: Outcomes from Moms2B Ohio. Maternal & Child

Health Journal, 21(5), 1130-1138. doi:10.1007/s10995-016-2211-x

Guillory, V. J., Lai, S. M., Suminski, R., & Crawford, G. (2015). Low birth weight in Kansas.

Journal of Health Care for the Poor and Underserved, 26(2), 577-602. Retrieved from

https://searchproquestcom.proxy.ohiolink.edu:9100/docview/1679411552?accountid=129

53

Hawley, N. L., Brown, C., Nu'usolia, O., Ah-Ching, J., Muasau-Howard, B., & McGarvey, S. T.

(2013). Barriers to adequate prenatal care utilization in American Samoa. Maternal &

Child Health Journal, 18(10), 2284-2292. doi:10.1007/s10995-013-1368-9

Liu, X., Behrman, J. R., Stein, A. D., Adair, L. S., Bhargava, S. K., Borja, J. B., . . . Sachdev, H.

S. (2017). Prenatal care and child growth and schooling in four low- and medium-income

countries. Plos ONE,12(2), 1-21. doi:10.1371/journal.pone.0171299

Loftus, C. T., Stewart, O. T., Hensley, M. D., Enquobahrie, D. A., & Hawes, S. E. (2015). A

longitudinal study of changes in prenatal care utilization between first and second births

and low birth weight. Maternal & Child Health Journal, 19(12), 2627-2635.

doi:10.1007/s10995-015-1783-1
EFFECTS OF PRENATAL CARE 15

Meghea, C. I, You, Z., & Roman, L. A. (2015). A statewide medicaid enhanced prenatal and

postnatal care program and infant injuries. Maternal & Child Health Journal, 19(10),

2119-2127. doi:10.1007/s10995-015-1724-z

Swartz, J. J., Hainmueller, J., Lawrence, D., & Rodriguez, M. I. (2017). Expanding prenatal

care to unauthorized immigrant women and the effects on infant health. Obstetrics &

Gynecology, 130(5), 938-945. doi:10.1097/AOG.0000000000002275

Xaverius, P., Alman, C., Holtz, L., & Yarber, L. (2016). Risk factors associated with very low

birth weight in a large urban area, stratified by adequacy of prenatal care. Maternal &

Child Health Journal, 20(3), 623-629. doi:10.1007/s10995-015-1861-4

VanderWeele, T. J., Lauderdale, D. S., & Lantos, J. D. (2013). Medically induced preterm birth

and the associations between prenatal care and infant mortality. Annals of Epidemiology,

23(7), 435-440. doi:10.1016/j.annepidem.2013.04.010