Interview #1:

'Pregnancy Behavior, Prenatal Care Can Influence Outcomes'

Elizabeth Armstrong, PhD, MPA, is an assistant professor of sociology and public affairs and a faculty affiliate with the Office of Population Research and the Center for Health and Well-Being at Princeton University. Dr. Armstrong holds a doctorate in sociology and demography from the University of Pennsylvania and a master’s degree in public affairs from Princeton. Her research focuses on the ways in which women and physicians understand and manage risk during pregnancy, and she is currently compiling a social history of pregnancy and prenatal care in the United States.

Q: Is prenatal care important?

A: Early prenatal care is "associated" with improved outcomes, but it is not clear that the relationship is causal. It may be that the women who begin prenatal care early are different in some important way from women who do not receive care until later, and these differences may account for the observed differences in birth outcome between the two groups. To the extent that prenatal care has any effect, it is most likely through screening for potential complications (like pre-eclampsia, reproductive tract infections, gestational diabetes and inadequate weight gain) that could threaten the mother's or the baby's health. A secondary benefit of prenatal care may be counseling about nutrition and health behaviors.

Q: What prenatal behaviors are associated with healthy pregnancy and having a healthy baby?

Diet — both eating nutritional foods and eating enough — is very important. It also is important to take certain vitamins and minerals, particularly folic acid and iron; to avoid or cut back on smoking, drug use and heavy drinking; to exercise; and to get adequate sleep. A lot of health behaviors recommended during pregnancy are important health behaviors for everybody, although they can be more important during pregnancy. For example, nutritional requirements are greater during pregnancy.

Q: What are the consequences of engaging in unhealthful behaviors during pregnancy?

A: We can associate behaviors like smoking, heavy alcohol and drug use and poor nutrition with low birth weight, which can have profound consequences at the time of birth and throughout the child’s life. Excessive alcohol use also is associated with an increased risk of fetal death, stillbirth and fetal alcohol syndrome. In addition, having an untreated sexually transmitted disease or infection can affect the pregnancy and can lead to an infection in the newborn or to preterm delivery, which is associated with low birth weight. Some researchers suspect that bacterial vaginosis, an infection of the vaginal tract, may be related to preterm delivery.

Q: Are some groups more likely to get early prenatal care?

A: About 83 percent of women in the United States begin prenatal care in the first trimester of pregnancy. The proportion is lower among blacks and Hispanics than among white women, and it is lower among women who are young, poor or less educated. Women with unintended pregnancies also are less likely to get early prenatal care; about half of women with unintended pregnancies don’t begin prenatal care until after the first trimester. Some studies have suggested that being in an abusive relationship can delay a woman’s entry into prenatal care. [6]

Q: What are some of the barriers to getting early prenatal care?

The three most common reasons women give for not getting prenatal care earlier are not knowing that they were pregnant, not having money or insurance coverage to pay for prenatal care and being unable to get an earlier appointment.

Q: What lifestyle changes should women make even before becoming pregnant?

A: Probably the best thing women can do before pregnancy is to be in good health — to eat a nutritious and adequate diet, to avoid smoking and heavy drinking, to avoid using illicit substances and to get adequate exercise and sleep. But these lifestyle and behavior changes can be hard to make. There is a lot of discussion now about teaching women who want to become pregnant to think about making changes that may be difficult and may require time to achieve success. That way, when they become pregnant, their health is good and they are not trying to make changes overnight.

Q: Is there any evidence that women who make positive lifestyle changes during pregnancy are likely to maintain those changes after pregnancy?

A: Many clinicians refer to pregnancy as a window of opportunity for women to change their behaviors, particularly behaviors like smoking and drinking. Most women want to have a healthy baby and are motivated to make changes. Because of physiological changes during pregnancy, too, many women report that they lose the taste for cigarettes or alcohol, which can make it easier to reduce substance use. Unfortunately, studies show that postpartum relapse rates are very high.

Q: How do psychosocial factors, like stress, affect pregnancy and birth outcomes?

A: We don’t understand these psychosocial factors as well as we ought to. The good news is that researchers are starting to explore the role of such factors as stress in pregnancy. Researchers also are looking at the role of domestic violence during pregnancy. Abuse can physically harm both the woman and the fetus, but it also can increase stress, which could have an adverse impact. Research shows that 4 percent to 8 percent of women experience domestic violence during pregnancy. [9] Those rates suggest that more pregnant women experience domestic violence during pregnancy than preeclampsia, gestational diabetes, anemia or placenta previa — conditions that we routinely screen for during prenatal care. Researchers and doctors are now trying to incorporate domestic violence screening into routine prenatal care.

Q: What role can health care professionals play in helping pregnant women make lifestyle changes?

A: Prenatal care provides an opportunity for a woman to have regular, sustained contact with a health care provider over a period of time. The median number of prenatal visits in the United States is 12.6. This means that over a period of seven or eight months, a woman has 12 or 13 visits with a health care provider — far more contact than most of us have with a doctor or other health care provider. That kind of sustained, intense relationship can be the key to making changes in behaviors like smoking. The thinking now is that clinicians should not just ask women about their behaviors during pregnancy but take a more active role to advise about behavior changes, to assist in finding ways to change behavior and to arrange help in smoking-cessation or other programs.

Q: What should be the woman's role in working with her health care provider during pregnancy?

A: Women need to communicate honestly with their doctors about smoking, drinking alcohol or other behaviors, as well as their use of any prescribed drugs, herbal remedies or nutritional supplements. Many people think that because something is labeled natural or they buy it over-the-counter it is safe to use during pregnancy, but that is not always the case. It also can be very important for women to continue to use prescribed drugs, such as asthma medication, during pregnancy if they have their doctors’ approval.

. Interview #2:

'Reducing Disparities to Improve Infant Health'

Andrew Racine, MD, PhD, is associate professor of pediatrics at the Albert Einstein College of Medicine and director of the Division of General Pediatrics at the Children’s Hospital at Montefiore in the Bronx, N.Y., where he treats an ethnically diverse population of lower socioeconomic status patients. His research focuses on the intersection of epidemiology and health economics and includes studies on the determinants of low birth weight and infant mortality in New York City. Dr. Racine holds a joint medical degree and doctorate in economics from New York University.

Q: How does the United States stack up against other nations in terms of infant mortality?

A: We are behind when compared to other industrialized countries, but that really is a function of the fact that our low birth weight rates are so high compared to other countries. You can think of infant mortality as a function of two factors — the rate at which children of any given birth weight die in the first year of life and the distribution of those weights in a population. If you look at any specific birth weight category, the United States does very well with regard to its infant mortality rate. For example, children who are born at less than 1,500 grams have better survival rates in the United States than in any other place in the world. The difficulty in the United States is the birth weight distribution. Although children born at less than 1,500 grams in the United States have a survival advantage compared to low birth weight children born in other countries, they are still at much greater risk of mortality than babies born at normal birth weights. Because we have so many more children born at low birth weights in the United States, it skews our infant mortality rates with respect to other countries.

Q: What is meant by the phrase "low birth weight?"

A: Less than 2,500 grams (about 5.5 pounds) is considered low birth weight, and less than 1,500 grams (about 3.3 pounds) is considered very low birth weight. The largest amount of morbidity is associated with very low birth weight babies, who are few in number but don’t do very well in terms of survival. The vast majority of complications related to low birth weight arise from premature birth.

Q: In the United States, are any ethnic or racial populations at greater risk of adverse birth outcomes?

A: The African-American population seems to be at greater risk for both low birth weight and infant mortality. What puts African-Americans at this increased risk, however, is not entirely clear. For example, studies have compared the black-white differential in civilian and military populations with respect to low birth weight or infant mortality. The military population is a self-selected population of relatively healthy people who have access to medical care. It turns out that the differences in infant mortality between black and white populations are significantly greater in the civilian population than in the military population, so access to care may be a factor. In addition, socioeconomic status and particularly maternal education level play important roles in the risk of low birth weight and infant mortality. People from lower economic backgrounds and lower educational backgrounds tend to have higher rates of low birth weight and infant mortality. Paradoxically, in some elements of the Latino population low birth weight rates are much lower than anticipated for a group with their socioeconomic profile.

Q: Are individual health behaviors during pregnancy important determinants of birth outcome within higher-risk populations?

A: Yes, somewhat. The largest behavioral risk factor that we know of for low birth weight is exposure to tobacco smoke during pregnancy. This is an example of a health behavior that’s amenable to intervention that could help reduce rates of low birth weight. Exposure to alcohol and recreational drugs is also associated with low birth weight. The crack epidemic of the late 1980s had a serious impact, creating an epidemic of low birth weight in New York City. Both black and white low birth weight rates had been on a continuous decline for about 30 years until early 1988, when they abruptly turned around. As that epidemic subsided in the early 1990s, we once again saw real improvements in low birth weight and infant mortality rates.

Q: Is access to prenatal care an important determinant of birth outcome for higher-risk populations?

A: Again, the answer is somewhat. Many studies have shown that prenatal care makes a big difference in terms of low birth weight rates. The problem, though, is that the studies are confounded by the issue of selection bias, meaning that women who are predisposed to getting prenatal care may have other unobservable behaviors that improve their likelihood of having a healthy baby. When you compare women who receive prenatal care early to women who do not, you can’t tease out the actual effect of the prenatal care from the effect of other variables.

Q: What progress has been made in recent years in improving birth outcomes?

A: We have made tremendous strides in the past 10 years at all levels of birth weight. Babies born weighing less than 1,500 grams have much better survival rates now than they did in 1990, and normal birth weight babies have much better survival rates in the first year of life than they did in 1990. Birth-weight-specific death rates have come down substantially through a combination of regionalization of neonatal intensive care units, better prenatal treatment and better neonatal care. However, we have not made much progress in the birth-weight distribution. In fact, we have seen changes in a negative direction. For example, there is evidence that the birth weight distribution in the white population has worsened over the past 10 years. A lot of that has to do with increased use of in vitro fertilization, resulting in big increases in the number of multiple gestations, which tend to be born smaller. Until we improve the birth weight distribution, we are not going to be able to achieve infant mortality rates of the level of France, Japan or Sweden. That is what we really need to work on.

Q: Are behavioral or educational interventions effective in preventing low birth weight in higher-risk groups?

A: Individual behaviors can be modified to reduce the likelihood of a woman having a low birth weight baby. Anyone who smokes should stop smoking. Anyone who does drugs should stop doing drugs. That is absolutely clear, but all kinds of things beyond an individual’s control also can have an impact. If we were to eliminate poverty tomorrow, we would greatly improve the low birth weight distribution in the United States. To the extent that we have not really made much progress in changing the distribution of economic resources in the United States over time, though, we have not made much progress in alleviating what is — at least partially — a poverty-associated condition.

Q: As a researcher and health care practitioner, what do you think should be done to reduce disparities in birth outcomes?

A: I firmly believe that there is a component to this problem that will be answered through basic medical research. Biomolecular research into the process of labor and the process of placental implantation and sufficiency is going to be very important in delineating why women go into labor and modifying when women go into labor. However, I also believe that there are large epidemiologic issues at work here. People of low socioeconomic background and certain minorities are at greater risk for low birth weight, but that is just one example of all kinds of health risks that these populations face. They also have higher levels of high blood pressure, higher levels of malignancies and higher levels of diseases of other kinds. When you see across-the-board morbidity associated with certain social conditions, you have to look at how you can ameliorate those social conditions, for example by improving access to care or control over other resources. We’ll make the biggest impact by addressing the issues that are underlying racial inequality and socioeconomic disparities. Ironically, those are the hardest things to identify and address.

Take Five to Help Pregnant Women Quit Smoking:

Quitting smoking is one of the most important steps a pregnant woman can take to reduce the risk of preterm birth, low birth weight and perinatal mortality.[3, 17] Nevertheless, at least 13 percent of women giving birth in the United States in 1998 smoked during their pregnancy, and the rate is much higher among some groups of women.[21]

To tackle this important public health concern, a coalition of government and private-sector health groups recently launched a campaign to encourage all prenatal care providers to adopt a simple five-step intervention that helps pregnant patients kick the habit. The intervention requires only five to 15 minutes during a routine prenatal office visit but is expected to increase smoking cessation rates by 30 to 70 percent.[17] It is adapted for pregnant women from a clinically effective strategy recommended by the U.S. Public Health Service.[8]

"We want to have every pregnant woman screened for smoking, and we want to have every pregnant smoker receive this evidence-based treatment," says Cathy Melvin, PhD, director of the Smoke Free Families National Dissemination Office at the University of North Carolina at Chapel Hill. Her office was established in 2000 with a grant from The Robert Wood Johnson Foundation to lead the way in identifying and disseminating smoking cessation best practices for pregnant women.

The "5-A" intervention begins by asking the patient about her smoking status — whether she smokes, has stopped smoking, has cut down or has continued to smoke as much as before she learned she was pregnant. Follow-up steps include advising her to quit, assessing her willingness to attempt to quit within 30 days, assisting her in quitting and arranging to track her progress.

Melvin says that one of the challenges in helping pregnant smokers quit is that at least one-fourth of them do not tell their health care providers they smoke. The 5-A intervention questionnaire used to ascertain smoking status has been carefully designed and increases disclosure of smoking by as much as 50 percent. Clinicians also are challenged by safety and efficacy concerns in using nicotine replacement therapy and other drugs with pregnant women.[3] Therefore, the five-step method recommends alternative support approaches, such as seeking a "quitting buddy."

"I’m excited about the potential public health impact this intervention can have as well as the fact that it’s a relatively simple, inexpensive and straightforward way to help pregnant smokers," Melvin notes. "We think we have an opportunity to keep infants healthy as well as improve women’s long-term health if they quit during pregnancy and beyond."

In addition to educating prenatal care providers about the five-step intervention, the National Dissemination Office will focus on developing reimbursement policies and system supports to help ensure that the intervention is adopted nationwide.

Pregnancy Intention: A Good Predictor of Prenatal Behavior?:

Research shows that unintended pregnancy may account for one-third to one-half of all pregnancies.[10, 12] Data from the 1995 National Survey of Family Growth showed that an estimated 48 percent of the more than 60 million women aged 15 to 44 living in the United States in 1994 had had at least one unplanned pregnancy within their lifetime [12] (66.6 percent of women aged 15 to 44 have had at least one pregnancy, planned or unplanned, within their lifetime [1]). Women who are younger, black, Hispanic, unmarried, less educated, or of low income are most likely to have unintended pregnancies.[10, 12]

More important, women who do not intend to become pregnant may be less likely to enter early prenatal care [14, 18, 19] — a key factor in achieving healthy outcomes for the baby and mother.[13] One study showed that unintended births among low-income women were 1.6 times more likely to involve delayed care, even when maternal age, status, education, having health insurance and other factors were considered.[16]

Although findings conflict, there is also evidence that unintended pregnancy may be associated with certain less-than-healthful maternal behaviors. For example, women with unintended pregnancies may be more likely than women with intended pregnancies to smoke cigarettes,[2, 11, 14] more likely to drink alcohol,[2] less likely to report daily vitamin use and less likely to cut back on caffeinated beverages [11] during pregnancy.

David J. Landry, MS, senior research associate at the Alan Guttmacher Institute, a not-for-profit organization in New York, observes that unintended pregnancy has been associated with certain prenatal behaviors. However, differences in behavior among women with planned and unplanned pregnancies might be better explained by factors other than pregnancy intention.

"When you control for age, poverty status or education, many of these behaviors fall out," says Landry. "For example, education is a much more powerful predictor of prenatal health behaviors than whether or not the pregnancy was intended."

"The bottom line is that, yes, intention status is a very important marker for significant behaviors and undesirable outcomes," Landry observes. "Intention status on its own is not necessarily responsible but is associated with a lot of other characteristics of pregnancy and the woman’s background."

The results of these studies underscore the need for health risk behavior and family planning counseling for all pregnant women, whether their pregnancies are intended or not.

Model Program Engages Inner-City Expectant Dads:

Much of the research on pregnancy and prenatal care focuses on the mother, but some experts argue that the father’s role before and after birth merits attention also. For example, studies suggest that adolescent fathers who are actively involved in the prenatal and neonatal periods are more likely to stay involved with their children [4] and that adolescent fathers who receive prenatal education may be more supportive of the mother and infant.[22]

Joseph Jones has seen firsthand the importance of involving expectant fathers, specifically those in Baltimore, Md. — where the rates of infant mortality, low birth weight and births to unmarried mothers are significantly higher than those of the rest of the state and the nation.[5, 15] While working as an addiction specialist for Baltimore’s federally funded Healthy Start program in the early 1990s, Jones saw a need and helped to establish the city-wide Men’s Services Initiative — a model, grassroots program that promotes responsible fatherhood within the inner-city African-American community.

"The fatherhood movement says to men, ‘We want you to be involved in the direct development of the child,’ but our family services historically have served women and children, not men," Jones asserts. "There are no public funding streams that serve men unless you want to consider the criminal justice system or the child support system. A segment of our society is reaching out, but when they reach out there’s nothing to hold onto."

The Men’s Services Initiative offers expectant fathers prenatal education and support, decision-making skills training, drug treatment referrals, employment services, criminal justice advocacy and case management services. Operated with federal and private funding by Jones’s non-profit Center for Fathers, Family and Workforce Development, the program has reached at least 700 fathers age 16 to 40 — most of whom are referred by women receiving Healthy Start services and recruited through persistent street outreach.

The services initially help participants set personal goals that say, "These are the things I need to do to be the kind of father I want to be, this is the kind of mate I want to be and this is the kind of citizen I want to be," Jones explains. Goals may include attending prenatal and pediatric appointments with the mother and participating in educational sessions and support groups. A 15-session curriculum then addresses topics such as fetal development, relationship issues, family health, domestic violence and decision-making.

Peter Schafer, executive director of Baltimore Healthy Start, adds that focus groups with men and women in Baltimore demonstrated that fathers are "very influential people" in the lives of pregnant women.

"Insofar as we can educate men about prenatal development, the influences on fetal development, family health and early childhood development and provide them support to be a more positive influence, we feel there will be a positive effect," said Schafer. "Having a baby is an opportunity for these guys to take a step back and view their lives as what they are for the child and not just what they are for themselves."

The Research:

1. Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ. (May 1997). Fertility, family planning and women’s health: New data from the 1995 National Survey of Family Growth. Vital and Health Statistics. Centers for Disease Control and Prevention, Series 23, No. 19.
   
   
2. Altfeld S, Handler A, Burton D, Berman L. (1997). Wantedness of pregnancy and prenatal health behaviors. Women and Health, 26(4):29-43.
   
   
3. American College of Obstetricians and Gynecologists. (2000). Smoking cessation during pregnancy. ACOG Educational Bulletin 260. Washington, DC.
   
   
4. Cox JE, Bithoney WG. (1995). Fathers of children born to adolescent mothers: Predictors of contact with their children at 2 years. Archives of Pediatric Adolescent Medicine, 149(9):962-6.
   
   
5. Curtin SC, Martin JA. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports, 48(14).
   
   
6. Dietz PM, Gazmararian JA, Goodwin MM, Bruce C, et al. (1997). Delayed entry into prenatal care: Effect of physical violence. Obstetrics and Gynecology, 90(2):221-4.
   
   
7. Ebrahim SH, Luman ET, Floyd RL, Murphy CC, et al. (1998). Alcohol consumption by pregnant women in the United States during 1988-1995. Obstetrics and Gynecology, 92(2):187-92.
   
   
8. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
   
   
9. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, et al. (1996). Prevalence of violence against pregnant women. The Journal of the American Medical Association, 275(24):1915-20.
   
   
10. Gilbert BJC, Johnson CH, Morrow B, Gaffield ME, Ahluwalia I. (1999). Prevalence of selected maternal and infant characteristics, Pregnancy Risk Assessment Monitoring System (PRAMS), 1997. Morbidity and Mortality Weekly Report, 48(SS05);1-37.
    
    
11. Hellerstedt WL, Pirie PL, Lando HA, Curry SJ, et al. (1998). Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. American Journal of Public Health, 88(4):663-6.
    
    
12. Henshaw SK. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30(1):24-9, 46.
    
    
13. Kiely JL, Kogan MD. (1994). Prenatal care. In: Reproductive Health of Women. Hyattsville, MD: National Center for Health Statistics.
    
    
14. Kost K, Landry DJ, Darroch JE. (1998). Predicting maternal behaviors during pregnancy: Does intention status matter? Family Planning Perspectives, 30(2):79-88.
    
    
15. Maryland Division of Health Statistics. Maryland Vital Statistics Annual Report 1998.
    
    
16. Mayer JP. (1997). Unintended childbearing, maternal beliefs and delay of prenatal care. Birth, 24(4):247-52.
    
    
17. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP, Goldenberg RL. (2000). Recommended cessation counselling for pregnant women who smoke: A review of the evidence. Tobacco Control, 9(Suppl III):iii80-4.
    
    
18. Pagnini DL, Reichman NE. (2000). Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart program. Family Planning Perspectives, 32(2):56-64.
    
    
19. Sable MR, Wilkinson DS. (1998). Pregnancy intentions, pregnancy attitudes and the use of prenatal care in Missouri. Maternal and Child Health Journal, 2(3):155-65.
    
    
20. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and Improving Health. 2nd Edition, Vol. I.
    
    
21. Ventura SJ, Martin JA, Curtin SC, Mathews TJ, Park M. (2000). Births: Final data for 1998. National Vital Statistics Reports, 48(3).
    
    
22. Westney OE, Cole OJ, Munford TL. (1988). The effects of prenatal education intervention on unwed prospective adolescent fathers. Journal of Adolescent Health Care, 9(3):214-8.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research, Academy of Psychosomatic Medicine, American Academy of Nursing, Association for Applied Psychophysiology and Biofeedback, American College of Neuropsychopharmacology, American Psychiatric Association, American Psychological Association, American Psychological Association-Division 38, American Psychological Society, American Psychosomatic Society, American Sociological Association, American Society of Psychiatric Oncology, College on Problems of Drug Dependence, Institute for the Advancement of Social Work Research, International Psycho-Oncology Society, International Society for Traumatic Stress Studies, Society of Behavioral Medicine, Society for Developmental and Behavioral Pediatrics, Society for Public Health Education, Society for Research on Nicotine and Tobacco.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Ira R. Allen
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Center for the Advancement of Health
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p. 202.387.2829 / f. 202.387-2857
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