Cuyahoga county death certificate

Characteristics of Inner-City Women Giving Birth with Little or No Prenatal Care: A Case-Control Study Lack of prenatal care has been identified as an important risk factor for poor perinatal outcomes. A case-control study was conducted to identify risk factors for inadequate prenatal care. Records of women giving birth at an inner-city hospital who had fewer than three prenatal visits (cases) were compared with those of women giving birth at the same hospital who had more adequate prenatal care (controls). The final sample contained 120 women in each group. Women in the case group were more likely to be multiparous, to be less educated, and to have no telephone in the home. Tobacco and drug abuse were recorded significantly more often among these women. There was no difference in racial distribution between the case and control groups. Infants of women with minimal or no prenatal care had a lower mean birthweight and a higher frequency of prematurity. In logistic regression analysis, higher parity, age less than 30 years, single status, smoking, drug abuse, and residence in one of two statistical planning areas in the city were independently associated with increased odds of not receiving prenatal care. To be effective, prenatal outreach programs for inner-city women must be based on knowledge of the characteristics and needs of this population.

Women who receive little or no prenatal care are a difficult group to locate and study. Research that has identified inadequate prenatal care as an important risk factor for poor perinatal outcomes has been based largely on birth and death certificate data or on computerized hospital databases. In these studies the relative risk of low birthweight and perinatal mortality is roughly double among women who receive little or no prenatal care. [1-4] The marked increase in infant mortality noted in Boston in 1982 has also been associated with inadequate prenatal care. [5] Birth certificates provide few data, however, on the characteristics of the population of women with inadequate or no prenatal care.

The few published studies that examine in greater depth the distinguishing characteristics of women who receive inadequate prenatal care give inconsistent conclusions. A 1971 study done at a public hospital in Atlanta found that patients without prenatal care were more likely to be white, older, and of higher parity and lower educational level than the prenatal clinic population at the same hospital. [6] A limited chart review of women giving birth without prenatal care suggested that internal (psychological) barriers to care may be more important than external (economic, practical) barriers. [7] A small uncontrolled study from Detroit has suggested that drug abuse (primarily heroin), financial barriers to care, attitude toward pregnancy, and attitude toward health professionals may be important determinants of whether women seek out prenatal care. [8] In New York City, in a larger study of women presenting for childbirth who had no prenatal care, it was found that cocaine abuse was very common and was associated with increased perinatal morbidity. [9] Findings of a large study based on birth certificate data from a low-risk health maintenance organization population indicated that despite apparently equal access to care, black women had fewer prenatal visits than white women. [4]

A recent Institute of Medicine report summarized results of published and unpublished studies on barriers to prenatal care. [10] Financial barriers, lack of awareness of the need for prenatal care, poor links to the health care system, and negative attitudes toward health care providers stood out as factors identified in many studies.

Although several factors related to low socioeconomic status have been associated with lack of prenatal care, many poor women successfully seek prenatal care. A study conducted at a University of Tennessee clinic that compared a sample of early resistrants for care with late registrants was unable to identify any clear factors distinguishing late registrants. [11] A study comparing early with late registrants for prenatal care in Harlem found that living with a husband or boyfriend a experiencing more than one stressful event in the previous year were positively associated with early registration. [12]

The study reported here addresses the following question: Within a low-income inner-city population, what distinguishes women who receive minimal or no prenatal care from other women who manage to obtain more adequate prenatal care? The relatively large number of minimal care patients in this study and the use of a control group drawn from the same county hospital population provided a new opportunity to examine these issues. The study also sought to verify the risk of poor outcomes in the infants of mothers with inadequate prenatal care.

The study hypotheses were that women with little or no prenatal care would be more likely to be black, older, and of higher parity; to have no medical insurance (including Medicaid); to abuse tobaclo, alcohol, or drugs; to have lower levels of education; to live in statistical planning areas of the city linked to high infant mortality rates; and to have maternal and neonatal morbidity and low-birthweight (<2500 g) infants.

Methods

Women in the case group were identified consecutively in a computerized database as all women (N=143) who gave birth in the 6-month period from January to June 1988 at MetroHealth Medical Center and had had two or fewer prenatal visits. The control group consisted of an equal number of women who had had three or more prenatal visits and who were delivered nearest in time (within 2 days) to a woman who gave birth in the case group. The computerized database had been compiled from abstracting forms completed by the clinician at the time of delivery. Subjects were excluded if, on review of the medical record, they had been misclassified in the database on the number of prenatal visits (39 subjects), if they had twins (6 subjects), or if the medical record could not be located (1 subject). The final number of subjects in each group was 120.

MetroHealth Medical Center (the county hospital for Cuyahoga County) serves an ethnically and racially diverse low-income inner-city community. During the 6-month time frame from which the sample was selected, there were 1816 deliveries. Of these women giving birth, 7.8% were identified as having two or fewer prenatal visits. Approximately 40% of the maternity population is black, 7% Hispanic, and 48% non-Hispanic white.

Medical records of case and control groups were reviewed by a trained medical record abstractor. Variables for which quantitative information was not consistently present, such as the amount of alcohol or drug use, were recorded as categorical variables.

The case group was compared with the control group using Student's t test for continuous variables and chi-square for categorical variables. Apgar scores were compared with the Mann-Whitney U test. To control for potential confounders and identify independent risk factors, logistic regression was performed using demographic and social characteristics as independent variables to estimate the odds of receiving little or no prenatal care. Logistic regression was done with the LOGISTIC program [13] using backward stepwise elimination. All other analyses were performed with the SPSS-PC statistical package. [14]

Results

Women in the case group, as expected, had a mean of 0.9 prenatal visits, whereas the mean for the control group was 9.2 visits. The majority of women in the case group received care only in the third trimester or not at all, whereas 80% of women in the control group started care in the first or second trimester (Table 1). There was no difference in mean age or age distribution between case and control groups. The racial distribution of the case group was strikingly similar to that of the control group and to that of the maternity population giving birth at MetroHealth Medical Center during the same period: 45% black, 42% white, and 7% Hispanic.

Most women in both groups were unemployed and on Medicaid at the time of delivery. Women in the case group were more likely to be of higher parity, to have no telephone, to have less education, and to use tobacco or illicit drugs. Women in the case group were also more often single and alcohol users, but these trends did not reach statistical significance (Table 2).