Quality of prenatal care as it relates to the source of prenatal care

As per World Health Organization (WHO) estimates, worldwide about 358,000 women die during pregnancy and childbirth every year.[1] The annual rate of decline in maternal mortality is less than half of what is needed to achieve the Millennium Development Goal (MDG) target of reducing the maternal mortality ratio by 75% between 1990 and 2015. This will require an annual decline of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%.[2]


INTRODUCTION
As per World Health Organization (WHO) estimates, worldwide about 358,000 women die during pregnancy and childbirth every year. [1]The annual rate of decline in maternal mortality is less than half of what is needed to achieve the Millennium Development Goal (MDG) target of reducing the maternal mortality ratio by 75% between 1990 and 2015.This will require an annual decline of 5.5%.The 34% decline since 1990 translates into an average annual decline of just 2.3%. [2]enatal care is commonly understood to have a benefi cial impact on pregnancy outcome.It provides an opportunity for healthcare providers to counsel mothers about behaviors that increase the likelihood of favorable maternal and fetal outcomes, and also about adverse pregnancy outcomes such as maternal morbidity/mortality, preterm birth, low birth weight, small-for-gestational age, and still birth.
Evidence related to the content, frequency, and timing of visits in antenatal care is known to have a defi nite infl uence on the outcome of pregnancy.Maternal reports on the quality/content of prenatal care (QPC) are likely to differ by the site/source of prenatal care (SPC) and maternal characteristics could infl uence the selection of SPC.
The present study has been conducted with an aim of studying the variation in counseling for prenatal care measures at different sources of care.In this context, the objectives include studying the relationship between the source of prenatal care and the quality of care administered, and simultaneously studying the infl uence of maternal characteristics on the selection of source of prenatal care.women in publicly funded and hospital clinics are more likely to receive adequate prenatal advise during pregnancy, than women in private offi ces and Health Managed Care Organizations (HMOs).
In a study by Sable and Patton, [5] the proportion of women who received prenatal advise to breastfeed and who intend to breastfeed were higher among married, Caucasian non-Hispanic, and primiparous mothers and women who were not enrolled in the Woman, Infants and Children Program.Leppert et al.'s, [6] study found that women aged 13-19 years (adolescents) were at increased risk for low birth weight babies (<2,500 g) and for preterm infants (<38 weeks gestation) even after controlling for antenatal care, ethnicity, and other factors.
Mustard and Roos [7] study shows that infants born to women in the poorest income quintile had lower birth weight than infants born to wealthier women, the reason being inadequate prenatal care among this group.The adequacy of prenatal care utilization (APNCU) index to study low birth weight and the bias therewith was studied by Koroukian and Rimm, [8] where-in an increasing number of prenatal visits were associated with improved birth outcomes. [9]study suggests that more frequent use of prenatal care can increase birth weight signifi cantly in Brazil.Beeckman et al.'s, [10] study shows a signifi cantly lower category of content and timing of antenatal care among lower educated women (odds ratio (OR): 0.58; 95% confi dence interval (CI): 0.37-0.92),women of Maghreb origin (OR: 0.38; 95% CI: 0.22-0.66),and women with a higher discontinuity of care (OR: 0.56; 95% CI: 0.34-0.90).

MATERIALS AND METHODS
PRAMS is an ongoing population-based surveillance system of maternal behaviors and experiences, before and during pregnancy and shortly after delivery of a live born infant.PRAMS was developed in 1987 by the Centre for Disease Control and Prevention (CDC) as part of their initiative to reduce poor pregnancy outcomes.Birth certifi cate is the primary tool for population-based surveillance of the condition of infants at birth and maternal status during pregnancy.Alternatively, PRAMS provides an important supplement to data from vital records for planning and assessing perinatal health programs on a state level.
Every month PRAMS samples approximately 130 live births from the New York State's birth certifi cate registry between 2 and 4 months after delivery.Mothers are sent up to three questionnaires with telephone follow-up for nonresponders.The survey consists of 68 questions that cover the period before conception, pregnancy, and the fi rst few months after delivery.All samples were reported in an unweighted format.

Statistical analysis
Our research study design is retrospective record-based cohort in nature.Using PRAMS data from 1996 to 1999, a total of 5,380 observations were used to study the relationship between SPC and QPC.Descriptive analysis (bivariate) and subsequent regression analysis were done using Statistical Analysis Software, version 8 (SAS-V8) with callable software: Survey Data Analysis (SUDAAN).Simple stratifi ed analysis was done using weighted data in SUDAAN.
The following fi gure illustrates the counseling effi ciency of each SPC stratifi ed by the QPC variable.The total values have been depicted (in terms of the percentage talked), irrespective of the maternal characteristics.HDC (>84%) counseled best and MD/ HMOs counseled badly (≤84%) for all the prenatal care measures, irrespective of the maternal characteristics.

Nutrition
For the variable nutrition, stratifi ed analysis shows that HDC counseled best among non-white (100%), mothers of middle and older age groups (>97%), and for all income groups (>96%).CHC counseled best among younger mothers (>99%).HC fared better for older mothers (>93%) and MD/HMOs performed badly across all strata of maternal characteristics.

Illegal drug use
The maternal characteristic illegal drug use when analyzed with various SPCs shows that HDC counseled best among older mothers (>99%) and middle income group (>94%).CHC counseled best among non-white mothers (>95%).MD/HMOs counseled better among young mothers (>88%), but fared badly with regard to other maternal characteristics.

Baby's growth
A stratifi ed analysis for the variable baby's growth shows that HDC performed best among non-white (>96%) and high income mothers (>91%).CHC fared best among low income (>95%) and young age group (>99%).HC and MD/HMOs counseled badly among most strata of maternal characteristics.

Smoking
Smoking as a variable when analyzed with SPC shows that HDC counseled best across all maternal characteristics (³94%     when assessed with age as a maternal characteristic, the data shows that mothers were best counseled about nutrition across all age strata.However, young mothers were less counseled about breastfeeding (85%), middle age mothers and older mothers were less counseled about illegal drug use (62.4 and 46.4%, respectively).Low and average income mothers were best counseled about nutrition (88 and 84.5%, respectively), whereas high income mothers were best counseled about baby's growth (87.3%).Across all income groups, illegal drug use was least counseled when compared with other QPC [Table 4].
Multivariate analysis was conducted using the SAS-V8.Results from the statistical model shows that QPC provided at HDC was signifi cantly good (P < 0.0001) when compared with MD/HMO.Also, mothers with an income of $30,000+ were signifi cantly likely (P < 0.00001) to receive good QPC when compared with low income groups (< $15,999).Older mothers (30+ years) were signifi cantly likely (P < 0.00001) to receive good QPC when compared with the younger mothers (< 20 years).
Quantifi cation of the association shows that QPC provided at HDC was twice (OR = 2.07, 95% CI: 1.6-2.518)better than that provided with MD/HMO.Also, mothers with an income of $30,000+ were one and a half times (OR = 1.56, 95% CI: 1.289-1.888)more likely to receive good QPC when compared with low income groups (<$15,999).Older mothers (30+ years) were also twice (OR = 2.096, 95% CI: 1.463-3.003)as likely to receive good QPC when compared with the younger mothers (< 20 years).

DISCUSSION
The data for our study is derived from PRAMS surveillance wherein mothers are surveyed with questionnaires and telephone follow-up is done for nonresponders.This conforms to the results from Colley et al.'s, [3] study; which shows that the mail/telephone methodology used in PRAMS is an effective means of reaching postpartal women.
White women predominantly visited MD/HMOs (87.8%) compared to non-white women who majorly accessed healthcare from HC (~60%).Race was observed to be a consistent predictor of PRAMS response in Colley et al.'s, [3] study; the data regarding which was not analyzed in our study.
HDC was most sought after by young mothers (22.5%), whereas a majority of middle-aged mothers accessed healthcare at HC (73.2%).MD/HMOs as a SPC was preferred by older mothers (20.7%).In comparison, Leppert et al.'s [6] study concluded that the amount of antenatal care is a more important predictor of pregnancy outcome than was maternal age.
Low income group (53.6%) preferred accessing healthcare from HC, whereas the average income group (26.9%) preferred CHCs.Among mothers seeking prenatal care at MD/HMOs, 67.8% were of the high income group.
Our study results show that counseling at HDC was most effi cient with regard to all the prenatal care measures (breastfeeding, nutrition, drug use, baby's growth, and smoking), when compared with the remaining four SPCs.MD/HMOs counseled less, wherein a comparative analysis shows that preventive counseling for all the fi ve topics was less (≤ 84%) when compared to the high (> 84%) percentage among all other SPCs.This is in concurrence with the results from Petersen et al.'s, [4] study which shows that women in publicly funded and hospital clinics are more likely to receive adequate prenatal advise during pregnancy than women in private offi ces and HMOs.
In our study, the data shows that irrespective of the maternal characteristics among HDC attendees the percentage of mothers who were spoken about breastfeeding was 96.3%, nutrition was 98.2%, drug use was 89%, baby's growth was 93.1%, and smoking was 95.9%.In comparison, among MD/HMO attendees the percentage of mothers who were spoken about breastfeeding was 76.6%, nutrition was 84%, drug use was 58.5%, baby's growth was 84%, and smoking was 71.5%.The results could be compared with Sable and Patton's [5] study, wherein only 37% of the study population reported that their providers advised them about breastfeeding.
Data analysis (considering all SPCs totally) for maternal characteristics infl uencing QPC shows that white mothers were best counseled about nutrition (84.9%) and least counseled about illegal drug use (61.7%).Non-white mothers were best counseled about baby's growth (90.1%) and least counseled about illegal drug use (70.8%).
The QPC data when assessed with age as a maternal characteristic shows that mothers were best counseled about nutrition across all age strata.However, young mothers were less counseled about breastfeeding (85%), middle age mothers and older mothers were less counseled about illegal drug use (62.4 and 46.4%, respectively).
Low and average income mothers were best counseled about nutrition (88 and 84.5%, respectively), whereas high income mothers were best counseled about baby's growth (87.3%).Across all income groups, illegal drug use was least counseled when compared with other QPC.In comparison, inadequate prenatal care was observed among low income women in Mustard and Roos's [7] study.
Multivariate analysis shows that good QPC was significantly associated with HDC (twice likely than MD/HMO), high income mothers (one and half times likely than low income groups), and older mothers (twice likely than younger mothers).
Based upon these prevalence data, we can conclude that variation in QPC among various SPC is likely.Maternal characteristics could likely infl uence the selection of SPC.Also the number of antenatal care visits could determine the birth outcome, which was not considered in our study.This association was considered in Koroukian and Rimm's [8] study which shows a direct association of increasing prenatal visits with improved birth outcome.Also, Wehby et al.'s, [9] study suggests that more frequent use of prenatal care can increase birth weight signifi cantly.A signifi cantly lower content and timing of care during pregnancy was found in Beeckman et al.'s, [10] study for women with a higher discontinuity of care.

CONCLUSION
The study advances current knowledge about the practice of preventive health counseling during prenatal care.It shows that variation exists in QPC among various SPC and maternal characteristics might infl uence the selection of SPC.
Child survival is directly dependent on good maternal health and nutrition.The strategies which are being devised for improving maternal and child health and their subsequent implementation for survival of the said vulnerable group, are closely related and need to be provided through a continuum of care approach.
Indices of prenatal care such as the Kessner index, GINDEX (Graduated prenatal care utilization index) or APNCU [8] could be used.Such models analyze the relationship between the adequacy of prenatal care and birth outcomes.

Limitations
• Preventive health counseling as reported by the patient might be different from what the healthcare provider reports.It could also be infl uenced by factors such as timing and number of prenatal visits.

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Recall bias is a potential problem.The quality of study data depends directly on the ability of study participants to recall (after delivery) and the counseling and behaviors that occurred during prenatal care.
• Additional research should be done to identify the temporal relationship between SPC and QPC and to identify for confounding factors such as maternal characteristics.
Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Figure 1 :
Figure 1: Source of prenatal care (total values) wherein the following QPC were talked about International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Table 1 : Source of prenatal care as it relates to quality/content of prenatal care (total values)
The table shows the number of mothers counseled about QPC in each of the SPC's.The total numbers are included.QPC = Quality of prenatal care, SPC = source of prenatal care, MD = Doctor of Medicine, HMO = Health Managed Care Organizations International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Table 2 : Source of prenatal care as it relates to maternal characteristics
The table refl ects the choice of mothers regarding SPC stratifi ed by their maternal characteristics.Appropriate column percentages are included.SPC = Source of prenatal care, MD = Doctor of Medicine, HMO = Health Managed Care Organizations

Table 3 : Quality of prenatal care as it relates to maternal characteristics
The given table illustrates the proportion of mothers counseled regarding QPC, stratifi ed by their maternal characteristics

Table 4 : The logistic procedure (SAS-V8) Analysis of maximum likelihood estimates Parameter DF Estimate Standard error Wald chi-square Pr>Chi-square
The table depicts the results of multivariate analysis, wherein the model determines the statistical association of QPC at various SPC and the infl uence of maternal characteristics.Quantifi ed values of the association are also included.QPC = Quality of prenatal care, SPC = source of prenatal care, SAS-V8 = Statistical Analysis Software, version 8