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Prenatal care

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Prenatal care
A doctor performs a prenatal exam.

Prenatal care, also known as antenatal care, is a type of preventive healthcare for pregnant individuals. It is provided in the form of medical checkups and healthy lifestyle recommendations for the pregnant person. Antenatal care also consists of educating the pregnant individual about maternal physiological and biological changes in pregnancy, along with prenatal nutrition; all of which prevent potential health problems throughout the pregnancy and promote good health for the parent and the fetus.[1][2] The availability of routine prenatal care, including prenatal screening and diagnosis, has played a part in reducing the frequency of maternal death, miscarriages, birth defects, low birth weight, neonatal infections, and other preventable health problems.

Prenatal Visits

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Traditional prenatal care in high-income countries generally consists of:

  • monthly visits during the first two trimesters (from the 1st week to the 28th week)
  • fortnightly visits from the 28th week to the 36th week of pregnancy
  • weekly visits after 36th week to the delivery, from the 38th week to the 42nd week
  • Assessment of parental needs and family dynamics

The WHO recommends that pregnant women should all receive at least eight antenatal visits to spot and treat problems and give immunizations. Although antenatal care is important to improve the health of both mother and baby, many women do not receive the recommended eight visits.[3] There is little evidence behind the number of antenatal visits pregnant women receive and what care and information is given at each visit.[4] It has been suggested that women who have low-risk pregnancies should have fewer antenatal visits.[4] However, when this was tested, women with fewer visits had babies who were much more likely to be admitted to neonatal intensive care and stay there for longer (though this could be down to chance results).[4]

A 2015 Cochrane Review findings buttresses this notion, with evidence that in settings with limited resources, where the number of visits is already low, programmes of ANC with reduced visits are associated with an increase in perinatal mortality.[4] Therefore, it is doubtful that the reduced visits model is ideal, even in low-income countries (LICs), where pregnant women are already attending fewer appointments.[2] Not only is visiting prenatal care early is highly recommended, but also a more flexible pathway allowing more visits, from the time a pregnant woman books for prenatal care, as it potentially enables more attention to those women who come late.[2] Also, women who had fewer antenatal visits were not as satisfied with the care they received compared with women who had the standard number of visits.[4]

Prenatal Examinations

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Main article: Prenatal testing

At the initial antenatal care visit, pregnant women are classified into either low risk or high risk.[5] Antenatal risk assessment began in the United Kingdom before becoming a widespread practice.[5]

Prenatal screening is testing for diseases or conditions in a fetus or embryo before it is born, and prenatal diagnosis refers to the official confirmation of these potential diseases of conditions. Obstetricians and midwives have the ability to monitor mother's health and prenatal development during pregnancy through series of regular check-ups.

Physical examinations generally consist of:

In some countries, such as the UK, the symphysial fundal height (SFH) is measured as part of antenatal appointments from 25 weeks of gestation.[6] (The SFH is measured from the woman's pubic bone to the top of the uterus.[7] A review into this practice found only one piece of research, so there is not enough evidence to say whether measuring the SFH helps to detect small or large babies.[8] As measuring the SFH is not costly and is used in many places, the review recommends carrying on this practice.[8]

Growth charts are a way of detecting small babies by the measuring the SFH.[9] There are two types of growth chart:

  1. Population-based chart, which shows a standard growth and size for each baby
  2. Customized growth chart, which is calculated by looking at the mother's height and weight, along with the weights of their previous babies.[9]

Examples of these growth charts are created by the World Health Organization and Centers for Disease Control and Prevention, which differ based on the sex of the infant, and can be found at: https://www.cdc.gov/growthcharts/who-charts.html A review looking into which of these charts detected small babies found that there is no good quality research to show which is best.[9] More research is needed before the customized growth charts are recommended because they cost more money and take more time for healthcare workers to make.[9]

Prenatal Ultrasounds

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Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:[citation needed]

"Pregnant baby chart" by jmoneyyyyyyy is licensed under CC BY 2.0.

Generally, an ultrasound is ordered whenever an abnormality is suspected, or along a schedule similar to the following:[citation needed]

  • 7 weeks — confirm pregnancy, ensure that it's neither molar nor ectopic, determine due date
  • 13–14 weeks (some areas) — evaluate the possibility of Down syndrome
  • 18–20 weeks — see the expanded list above
  • 34 weeks (some areas) — evaluate the size, verify the placental position

A review looking at routine ultrasounds past 24 weeks found that there is no evidence to show any benefits to the mother or the baby.[10]

Early scans mean that multiple pregnancies can be detected at an early stage of pregnancy[11] and also gives more accurate due dates so that fewer women are induced who do not need to be.[11]

Levels of feedback from the ultrasound can differ. High feedback is when the parents can see the screen and are given a detailed description of what they can see.[12] Low feedback is when the findings are discussed at the end and the parents are given a picture of the ultrasound.[12] The different ways of giving feedback affect how much the parents worry and the mother's health behaviour, although there is not enough evidence to make clear conclusions.[12] In a small study, mothers receiving high feedback were more likely to stop smoking and drinking alcohol, however, the quality of the study is low, and more research is needed to say for certain which type of feedback is better.[12]

Women experiencing a complicated pregnancy may have a test called a Doppler ultrasound to look at the blood flow to their unborn baby.[13] This is performed to detect signs that the baby is not getting a normal blood flow and therefore is 'at risk'. A review looked at performing Doppler ultrasounds on all women, even if they were at 'low risk' of having complications.[13] The review found that routine Doppler ultrasounds may have reduced the number of preventable baby deaths, but the evidence was not strong enough to recommend that they should be made routine for all pregnant women.[13]

Prenatal Nutrition

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Main article: Prenatal nutrition

Prenatal care not only applies to the parent carrying the baby, but it also applies to the sperm donor. Sperm affects the fetus's ability to grow properly, and proper nutrition is one of the main factors.[14] For example, a zinc deficiency can lead to sperm deformations and reduced sperm motility which can cause infertility or improper fertilization of the egg, which has the potential to cause miscarriages or fetal deformities.[14] Spina bifida, which is caused by a folic acid deficiency, is another example of the effects of prenatal malnutrition.[15] Foods are typically fortified with folic acid to reduce this, but some flours like masa flour are not within those federal outlines,[16] which is theorized to be why Hispanic women are most likely to have children with spina bifida.[15] Because of all this, it is normally encouraged that women take a prenatal vitamin to prevent these fetal deformations and deficiency symptoms.[17]

Exercise Intensity and Delivery Outcomes

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Research suggests that physical activity levels during pregnancy can impact delivery outcomes.[18] A study examining the effects of exercise intensity on delivery type and risk of preterm birth found that varying levels of physical activity were linked to different pregnancy outcomes and associated risks.

Very low levels of physical activity are associated with an increased risk of both preterm and instrumental deliveries.[19] Pregnant individuals with minimal activity may experience lower overall fitness and muscle tone, which can impact the body's ability to manage the physical demands of labor. Another study showed that individuals with higher handgrip strength are more likely to have a vaginal delivery, as greater muscle strength and endurance can support the labor process. In contrast, those who gained more weight during pregnancy or had larger arm and calf circumferences were more likely to undergo cesarean delivery, particularly in cases of nonprogressive labor.[20] Low levels of physical activity during pregnancy have been linked to a slightly elevated risk of cesarean delivery.[19] Regular moderate exercise may help enhance pelvic muscle tone and cardiovascular fitness, potentially reducing the likelihood of cesarean intervention by supporting the body's endurance during labor.

For individuals seeking to engage in levels of vigorous or high-intensity physical activity, one study did observe a slight increase in instrumental delivery, which involves the use of medical tools like forceps or vacuum devices.[19] More intense physical activity may add extra demands on the body, potentially affecting labor progression and increasing the need for instrumental assistance. [19] Pregnant individuals need to consult with their healthcare provider before beginning or adjusting exercise routines, particularly if they are new to regular physical activity or have any health conditions that may affect pregnancy by adding additional stress to the body.[19]

Types of Care

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Individual vs Group Care

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Group prenatal care, in recent years, has been implemented in around 22 countries that are aiming to improve maternal care.[21] This type of care offers a group of multiple pregnant people (typically around 8-12 of them that are in a similar stage of pregnancy) to see one or more providers simultaneously, along with following up every few weeks to these group appointments for continual care.[21] Group antenatal care is beneficial in terms of reduced cost, increased education, and increased sense of support.[21] It has also been found that women who used group prenatal care visits were more likely to utilize family planning services after the baby had been delivered.[21]

Midwife-led Care

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Midwife-led care is where a midwife team (and general practitioner, if needed) leads the care a woman receives, and she does not usually see a specialist doctor during her pregnancy.[22] Midwife-led care is typically used by women with low-risk pregnancies. Women with midwife-led pregnancies are more likely to give birth without being induced, instead, they partake in natural labor. However, they are less likely to have their waters broken, an instrumental delivery, episiotomy or preterm birth.[23] However, around the same number of women in each group underwent a caesarean section.[23]

Self-led Care

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In many countries, women are given a summary of their case notes, including important background information about their pregnancy, such as their medical history, growth charts, and scan reports.[24] If the mother goes to a different hospital for care or to give birth the summary of her case notes can be used by the midwives and doctors until her hospital notes arrive.[24] A review looking into women keeping their case notes shows they have a higher risk of having a caesarean section.[24] However, the women reported feeling more in control having their notes and would like to have them again in future pregnancies.[24] 25% of women reported their hospital notes were lost in the hospital, though none of the women forgot to take their notes to any appointments.[24]

Access to Prenatal Care

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In 2018, it was found that a million women in the United States did not receive adequate prenatal care, which was defined as attending 80 percent of the recommended prenatal care visits or beginning prenatal care during the first trimester.[25] Transportation is one of the biggest threats to prenatal care access, making it hard for pregnant people in rural communities to have access to proper prenatal care. Specifically, over half of the people in rural areas who are seeking prenatal care have to travel at least 30 minutes to receive care, and there are higher rates of clinic closures in rural areas. Because of Telemedicine, the gap in care due to transportation issues has been reduced.

Telemedicine

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A new alternative for some of the routine prenatal care visits is Telemedicine, which is an online route of performing these prenatal appointments, and became more of a standardized practice due to the COVID pandemic.[26] Specifically, over half of pregnant women were afraid of stepping foot inside a hospital because of the risk of contracting the virus, so Telemedicine offered a way of communication that was not face to face, but would still get people the care they required.[26] In depth obstetric examinations and blood work are not possible through Telemedicine, but other appointment tasks are possible, such as using personal devices to detect fetal heart rate, conducting maternal mental health consults, and general sharing of information between provider and patient.[26] Overall, Telemedicine is seen as an improvement in prenatal care because it offers the potential for higher accessibility of care to marginalized groups.[25] However, it does tend to be younger, White patients who utilize Telemedicine because of their increased access to and familiarity with technology.[25]

Racial Health Disparities

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Main article: Racial health disparities

Racial differences are also prevalent in prenatal care, especially because there is a trend of reduced funding for Black and Hispanic communities.[25] All racial minorities also experience higher levels of perinatal mortality, especially Black individuals.[27] Racial minorities are also more likely to have high-risk pregnancies and conditions such as preeclampsia, gestational diabetes, and gestational hypertension. [27] Because race and class are very heavily intertwined, there is a complex relationship between race and preterm birth risks that cannot be simplified into a specific cause.[28] However, pregnant Black women who encounter racism end up having physiological changes in their amniotic fluid and alterations in immune and endocrine mechanisms. [28] Women of color are less likely to access prenatal care within the first trimester than white women, along with Black women having the least amount of access to prenatal care out of all racial minorities. [29]

Class-based Health Disparities

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The World Health Organization (WHO) reported that in 2015, around 830 women died every day from problems in pregnancy and childbirth.[30] Only 5 lived in high-income countries, and the rest lived in low-income countries.[30] A study examined the differences in early and low-weight birth deliveries between local and immigrant women and saw that the difference was caused by receiving prenatal care.[31] The study, between 1997 and 2008, looked at 21,708 women giving birth in a region of Spain. The results indicated that very preterm birth (VPTB) and very low birth weight (VLBW) were much more common for immigrants than locals.[31] The study showed the importance of prenatal care and how universal prenatal care would help people of all origins get proper care before pregnancy/birth. [31]

Increasing Access

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There are many ways of changing health systems to help women access antenatal care, such as new health policies, educating health workers, and health service reorganization.[32] Community interventions to help people change their behavior can also play a part. Examples of interventions are media campaigns reaching many people, enabling communities to take control of their health, informative-education-communication interventions, and financial incentives.[32] A review looking at these interventions found that one intervention helps improve the number of women receiving antenatal care.[32] However, interventions used together may reduce baby deaths in pregnancy and early life, lower the number of low birth weight babies born, and improve the number of women receiving antenatal care.[32]

See also

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References

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  1. ^ "WHO recommendations on antenatal care for a positive pregnancy experience". www.who.int. Retrieved 2021-12-04.
  2. ^ a b c David, Rodreck; Evans, Ruth; Fraser, Hamish SF (2021-01-01). "Modelling Prenatal Care Pathways at a Central Hospital in Zimbabwe". Health Services Insights. 14: 11786329211062742. doi:10.1177/11786329211062742. ISSN 1178-6329. PMC 8647229. PMID 34880627.
  3. ^ "WHO recommendation on antenatal care contact schedules". WHO. World Health Organization. Retrieved July 30, 2020.[dead link‍]
  4. ^ a b c d e Dowswell, T; Carroli, G; Duley, L; Gates, S; Gülmezoglu, AM; Khan-Neelofur, D; Piaggio, G (16 July 2015). "Alternative versus standard packages of antenatal care for low-risk pregnancy". The Cochrane Database of Systematic Reviews. 2015 (7): CD000934. doi:10.1002/14651858.CD000934.pub3. PMC 7061257. PMID 26184394.
  5. ^ a b Board on Children, Youth; Medicine, Institute of; Council, National Research (2013-09-23), "Assessment of Risk in Pregnancy", An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary, National Academies Press (US), retrieved 2025-04-21
  6. ^ "Antenatal care for uncomplicated pregnancies". NICE. National Institute for Health Care and Excellence. 26 March 2008. Retrieved September 23, 2017.
  7. ^ "Fetal Growth - Fundal Height Measurements". Perinatal Institute. Retrieved September 23, 2017.
  8. ^ a b Robert Peter, J; Ho, JJ; Valliapan, J; Sivasangari, S (8 September 2015). "Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth". The Cochrane Database of Systematic Reviews. 2015 (9): CD008136. doi:10.1002/14651858.CD008136.pub3. PMC 6465049. PMID 26346107.
  9. ^ a b c d Carberry, AE; Gordon, A; Bond, DM; Hyett, J; Raynes-Greenow, CH; Jeffery, HE (16 May 2014). "Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women". The Cochrane Database of Systematic Reviews. 2014 (5): CD008549. doi:10.1002/14651858.CD008549.pub3. PMC 7175785. PMID 24830409.
  10. ^ Bricker, L; Medley, N; Pratt, JJ (29 June 2015). "Routine ultrasound in late pregnancy (after 24 weeks' gestation)". The Cochrane Database of Systematic Reviews. 2015 (6): CD001451. doi:10.1002/14651858.CD001451.pub4. PMC 7086401. PMID 26121659.
  11. ^ a b Whitworth, M; Bricker, L; Mullan, C (14 July 2015). "Ultrasound for fetal assessment in early pregnancy". The Cochrane Database of Systematic Reviews. 2015 (7): CD007058. doi:10.1002/14651858.CD007058.pub3. PMC 4084925. PMID 26171896.
  12. ^ a b c d Nabhan, AF; Aflaifel, N (4 August 2015). "High feedback versus low feedback of prenatal ultrasound for reducing maternal anxiety and improving maternal health behaviour in pregnancy". The Cochrane Database of Systematic Reviews. 2015 (8): CD007208. doi:10.1002/14651858.CD007208.pub3. PMC 6486291. PMID 26241793.
  13. ^ a b c Alfirevic, Z; Stampalija, T; Medley, N (15 April 2015). "Fetal and umbilical Doppler ultrasound in normal pregnancy". The Cochrane Database of Systematic Reviews. 4 (4): CD001450. doi:10.1002/14651858.CD001450.pub4. PMC 4171458. PMID 25874722.
  14. ^ a b Fallah, Ali; Mohammad-Hasani, Azadeh; Colagar, Abasalt Hosseinzadeh (2018). "Zinc is an Essential Element for Male Fertility: A Review of Zn Roles in Men's Health, Germination, Sperm Quality, and Fertilization". Journal of Reproduction & Infertility. 19 (2): 69–81. ISSN 2228-5482. PMC 6010824. PMID 30009140.
  15. ^ a b CDC (2025-01-02). "Data and Statistics". Spina Bifida. Retrieved 2025-03-05.
  16. ^ Hamner, Heather C.; Tinker, Sarah C. (2014). "Fortification of corn masa flour with folic acid in the United States: an overview of the evidence". Annals of the New York Academy of Sciences. 1312 (1): 8–14. Bibcode:2014NYASA1312....8H. doi:10.1111/nyas.12325. ISSN 1749-6632. PMC 4480372. PMID 24494975.
  17. ^ Freedman, Robert; Hunter, Sharon K.; Hoffman, M. Camille (July 2018). "Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy". American Journal of Psychiatry. 175 (7): 607–619. doi:10.1176/appi.ajp.2018.17070836. ISSN 0002-953X. PMC 6984656. PMID 29558816.
  18. ^ Hinman, Sally K.; Smith, Kristy B.; Quillen, David M.; Smith, M. Seth (November 2015). "Exercise in Pregnancy: A Clinical Review". Sports Health: A Multidisciplinary Approach. 7 (6): 527–531. doi:10.1177/1941738115599358. ISSN 1941-7381. PMC 4622376. PMID 26502446.
  19. ^ a b c d e Takami, Mio; Tsuchida, Akiko; Takamori, Ayako; Aoki, Shigeru; Ito, Mika; Kigawa, Mika; Kawakami, Chihiro; Hirahara, Fumiki; Hamazaki, Kei; Inadera, Hidekuni; Ito, Shuichi; and the Japan Environment & Children's Study (JECS) Group (2018-10-29). Rosenfeld, Cheryl S. (ed.). "Effects of physical activity during pregnancy on preterm delivery and mode of delivery: The Japan Environment and Children's Study, birth cohort study". PLOS ONE. 13 (10): e0206160. Bibcode:2018PLoSO..1306160T. doi:10.1371/journal.pone.0206160. ISSN 1932-6203. PMC 6205641. PMID 30372455.
  20. ^ ErtüRk çEli̇K, GüLsemi̇N; ErtüRk Aksakal, Sezi̇N; Engi̇N üStüN, Yaprak (2024-10-18). "The impact of maternal muscle strength on cesarean delivery outcomes: a comparative study of nulliparous women". Turkish Journal of Medical Sciences. 54 (5): 908–914. doi:10.55730/1300-0144.5867. ISSN 1300-0144. PMC 11518347. PMID 39473746.
  21. ^ a b c d Andrade-Romo, Zafiro; Heredia-Pi, Ileana B.; Fuentes-Rivera, Evelyn; Alcalde-Rabanal, Jacqueline; Cacho, Lourdes Bravo Bolaños; Jurkiewicz, Laurie; Darney, Blair G. (2019-09-27). "Group prenatal care: effectiveness and challenges to implementation". Revista de Saúde Pública. 53: 85. doi:10.11606/s1518-8787.2019053001303. ISSN 1518-8787. PMC 6763281. PMID 31576945.
  22. ^ "Everything NICE says on a topic in an interactive flowchart". NICE. National Institute for Health Care and Excellemce. Retrieved September 23, 2017.
  23. ^ a b Sandall, J; Soltani, H; Gates, S; Shennan, A; Devane, D (28 April 2016). "Midwife-led continuity models versus other models of care for childbearing women" (PDF). The Cochrane Database of Systematic Reviews. 2016 (4): CD004667. doi:10.1002/14651858.CD004667.pub5. PMC 8663203. PMID 27121907.
  24. ^ a b c d e Brown, HC; Smith, HJ; Mori, R; Noma, H (14 October 2015). "Giving women their own case notes to carry during pregnancy". The Cochrane Database of Systematic Reviews. 2015 (10): CD002856. doi:10.1002/14651858.CD002856.pub3. PMC 7054050. PMID 26465209.
  25. ^ a b c d Wu, Katrina K.; Lopez, Cristina; Nichols, Michelle (2022). "Virtual Visits in Prenatal Care: An Integrative Review". Journal of Midwifery & Women's Health. 67 (1): 39–52. doi:10.1111/jmwh.13284. ISSN 1542-2011. PMID 34767317.
  26. ^ a b c Wu, Huailiang; Sun, Weiwei; Huang, Xinyu; Yu, Shinning; Wang, Hao; Bi, Xiaoyu; Sheng, Jie; Chen, Sihan; Akinwunmi, Babatunde; Zhang, Casper J P; Ming, Wai-Kit (2020-07-22). "Online Antenatal Care During the COVID-19 Pandemic: Opportunities and Challenges". Journal of Medical Internet Research. 22 (7): e19916. doi:10.2196/19916. ISSN 1438-8871. PMC 7407486. PMID 32658860.
  27. ^ a b Healy, Andrew J.; Malone, Fergal D.; Sullivan, Lisa M.; Porter, T Flint; Luthy, David A.; Comstock, Christine H.; Saade, George; Berkowitz, Richard; Klugman, Susan; Dugoff, Lorraine; Craigo, Sabrina D.; Timor-Tritsch, Ilan; Carr, Stephen R.; Wolfe, Honor M.; Bianchi, Diana W. (March 2006). "Early Access to Prenatal Care: Implications for Racial Disparity in Perinatal Mortality". Obstetrics & Gynecology. 107 (3): 625–631. doi:10.1097/01.AOG.0000201978.83607.96. ISSN 0029-7844. PMID 16507934.
  28. ^ a b Kramer, Michael R.; Hogue, Carol J.; Dunlop, Anne L.; Menon, Ramkumar (2011). "Preconceptional stress and racial disparities in preterm birth: an overview". Acta Obstetricia et Gynecologica Scandinavica. 90 (12): 1307–1316. doi:10.1111/j.1600-0412.2011.01136.x. ISSN 1600-0412. PMC 5573146. PMID 21446927.
  29. ^ Silva, Pedro Henrique Alcântara da; Aiquoc, Kezauyn Miranda; Silva Nunes, Aryelly Dayane da; Medeiros, Wilton Rodrigues; Souza, Talita Araujo de; Jerez-Roig, Javier; Barbosa, Isabelle Ribeiro (2022-07-04). "Prevalence of Access to Prenatal Care in the First Trimester of Pregnancy Among Black Women Compared to Other Races/Ethnicities: A Systematic Review and Meta-Analysis". Public Health Reviews. 43. doi:10.3389/phrs.2022.1604400. ISSN 2107-6952. PMC 9289875. PMID 35860809.
  30. ^ a b "Maternal mortality". WHO. World Health Organization. Retrieved September 23, 2017.
  31. ^ a b c Castelló, Adela; Río, Isabel; Martinez, Encarnación; Rebagliato, Marisa; Barona, Carmen; Llácer, Alicia; Bolumar, Francisco (2012-03-01). "Differences in Preterm and Low Birth Weight Deliveries Between Spanish and Immigrant Women: Influence of the Prenatal Care Received". Annals of Epidemiology. 22 (3): 175–182. doi:10.1016/j.annepidem.2011.12.005. ISSN 1047-2797. PMID 22285869.
  32. ^ a b c d Mbuagbaw, L; Medley, N; Darzi, AJ; Richardson, M; Habiba Garga, K; Ongolo-Zogo, P (1 December 2015). "Health system and community level interventions for improving antenatal care coverage and health outcomes". The Cochrane Database of Systematic Reviews. 12 (12): CD010994. doi:10.1002/14651858.CD010994.pub2. PMC 4676908. PMID 26621223.

Further reading

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