Running Head : MATERNAL CHILD HEALTH OUTCOMES 1 Are Maternal Child Health Outcomes Affected by Adequacy of Prenatal Care in Montgomery County , OH ?

Background: Prenatal Care has been recommended by the World Health Organization for all pregnant women in order to improve health outcomes of the mother and the child. However, recommendations for the number of visits required to provide adequate health care and improve outcomes continue to be debated. Understanding if adequate prenatal care is improving maternal child outcomes is essential before making these recommendations. This research aims to determine if in Montgomery County, OH the adequacy of prenatal care influenced gestational age at birth, birth weight, breastfeeding rate, rate of cesarean sections, and smoking cessation rates. Methods: De-indentified birth data was collected from Public Health Dayton & Montgomery County for 2007-2009. Data regarding patient demographics, number of prenatal visits, gestational age of newborn, birth weight, breastfeeding rate, smoking cessation, and method of delivery was extrapolated from the original data set. Using ACOG guidelines, the number of women who received adequate (11 or more prenatal visits) and inadequate prenatal care and their outcomes (gestational age, birth weight, breastfeeding, cesarean section rate, and smoking cessation) was determined. Chi squared, Odds Ratio’s, and logistic regression were used to determine statistical significance for each outcome based on adequacy of prenatal care. Results: The odds of having a premature baby were significantly increased (OR 1.78; CI1.61, 1.97) for woman who received inadequate prenatal care. Odds of low birth weight for inadequate prenatal care (<11 visits) was 1.89 (1.71-2.08). The odds of breastfeeding were 1.6 (1.52; 1.72) times greater if having received adequate prenatal care, the odds of receiving a cesarean section with adequate prenatal care was 1.23 (CI: 1.14; 1.32), and the odds of quitting smoking was 1.21 (CI: 1.00; 1.46). Conclusion: Adequate prenatal care positively affected the risk of premature birth, low birth weight, and significantly increased breastfeeding rates. However, risk of cesarean section was significantly more likely if the woman received adequate prenatal care, raising concern for inappropriate encouragement by physicians. Smoking cessation rates showed no difference based on adequacy of prenatal care which demonstrated that woman who quit smoking were motivated by something more than just increased interaction with their physician. MATERNAL CHILD HEALTH OUTCOMES 4 Are Maternal Child Health Outcomes Affected by Adequacy of Prenatal Care in Montgomery County, OH? Prenatal care is defined by the World Health Organization (WHO) as healthcare during pregnancy that constitutes “screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes, providing therapeutic interventions known to be effective; and educating pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them” (WHO, Statistical Information System, 2008). It is estimated by the Department for Health and Human Services (2009) that women who do not receive prenatal health care are three times more likely to have a low birth weight baby and babies of mother’s who do not receive prenatal care are five times more likely to die. Furthermore, a study of Missouri’s Medicaid patients found that mother’s receiving adequate prenatal healthcare (defined by the Kessner Index) saved the health care system an average of $1.49 per $1.00 spent on prenatal care (Schramm, 1992). Adequate prenatal health care has been defined by numerous different indices. The first prenatal healthcare began in Europe with the recommendation of 16 visits during pregnancy (Carroli, Rooney, & Villar, 2001). However, Carroli et al. (2001) found in a meta analysis of over 60,000 women that when four prenatal visits did not occur, there was an increased risk for any of the reviewed perinatal outcomes (including low birth weight and infant mortality). This led the WHO to define adequate prenatal care as four prenatal care visits, recommended for all pregnant women globally. However, other indices have been developed such as the Kessner Index/Institute of Medicine Index which states for a pregnancy 36 weeks, a woman should received at least 9 prenatal visits to be considered “adequate. ” However, this index defines “inadequate” as a women  34 weeks gestation receiving less than four prenatal visits and MATERNAL CHILD HEALTH OUTCOMES 5 everything in between as “intermediate” (Kotelchuck, 2001). The American College of Obstetricians and Gynecologists (ACOG) and the US Department of Health and Human Services both recommend adequate prenatal care as once monthly visits beginning between weeks 6-8 through 28 weeks and twice monthly visits between weeks 29-36. This equates adequate prenatal health care to 10 visits at 36 weeks gestational age. The guidelines recommend weekly thereafter 36 weeks, thus a full term 37 week gestation should have 11 prenatal visits (American Congress of Obstetricians and Gynecologists, 2011). The Adequacy of Prenatal Care Utilization Index (APNCU) states adequate prenatal care should start in the fourth month or earlier and should constitute at least 80% of the ACOG recommendations. Intermediate care begins in months five or six and is 50-79% of ACOGs guidelines and inadequate prenatal care was documented as care beginning greater than the sixth month of gestation and less than 50% of the number of visits recommended by ACOG (Kotelchuck, 1994). This leads to the question, what is adequate prenatal health care and what does it do? In the United States, the standard of care is the ACOG guidelines, which recommend 11 visits for a 37-week baby. According to the WHO (2012), adequate prenatal care provides a method for early detection and intervention of the leading causes of morbidity and mortality of both the pregnant woman and her baby during the pregnancy and immediately following, ensuring the healthiest pregnancy and delivery as possible. In addition, it allows for contact with an educated medical professional giving an opportunity for education regarding healthy habits for both the mother and baby. It is recommended at all prenatal visits in the US to screen for tobacco, alcohol, and drug use and provide appropriate counseling. In addition, at each visit, it is recommended that there be discussion and promotion of breastfeeding. This is in addition to physical exams including approximate size and gestational age of the baby, listening to heart MATERNAL CHILD HEALTH OUTCOMES 6 tones, screening exams, lab tests, and cultures that occur through out the pregnancy (Prenatal Care Schedule; Wellmark Blue Cross and Blue Shield, 2011). Although the goal of prenatal healthcare is to decrease morbidity and mortality for both the mother and baby, there has been an unfortunate spike in cesarean section rates in western cultures for “no indicated reason. ” It has been documented that up to 21% of cesarean sections have been found at a later date to be “inappropriate” and up to 14% to have no clear advantage or disadvantage (Ostovar et al., 2010). Cesarean sections provide enormous benefit to the outcomes of both the mother and the baby when used appropriately. However, when used inappropriately, the surgery and procedure for both the mother and baby poses unnecessary harm and health risks. The increasing rate of cesarean sections has rising more dramatically in western cultures, where on average, more women receive adequate prenatal health care. This poses a potential concern that increasing number of prenatal care visits is coinciding with an increased cesarean section rate, which may in up to 21% of the cases cause more potential harm that good. This, unfortunately, is the exact opposite effect that prenatal health care is supposed to have on pregnant women and their unborn babies. Due to the perceived benefits of adequate prenatal health care and the stated risks involved with inadequate prenatal health care, prenatal health care in Montgomery County, Ohio and the United States, is a resource offered to all pregnant women either through private insurance or through free clinics. However, this research proposes to determine if adequate prenatal care in Montgomery County, Ohio has given the improved maternal child health outcomes that it is aimed to provide. Specifically, this paper will determine if having received adequate prenatal health care in Montgomery County, Ohio between the years 2007-2009 showed improved outcomes of prematurity, low birth weight, likelihood to breastfeed at MATERNAL CHILD HEALTH OUTCOMES 7 discharge from the hospital, and smoking cessation rates. Furthermore, this paper also assesses the incidence of cesarean sections based on number of prenatal visits. Additionally, the demographics of the women not receiving adequate prenatal care are determined in order to better understand the population at risk. It is of utmost importance to understand the impact prenatal care on the health outcomes of women and babies. This information will allow medical professionals to better understand the true effects of adequate prenatal care in Montgomery County, OH and aims to offer areas of improvement for better outcomes. Statement of Purpose 1) What are the demographics of the women receiving adequate vs. inadequate prenatal care in Montgomery County, Ohio for years 2007-2009? 2) Are there differences in maternal child outcomes for those women who receive adequate vs. inadequate prenatal care? Outcomes include:  Gestational Age  Birth Weight  Method of delivery (vaginal vs. cesarean section)  Likelihood to breastfeed upon discharge from hospital  Smoking cessation