at the end of pregnancy reflects the historical roots of
prenatal care in the detection of preeclampsia/
eclampsia, a systemic hypertensive-related disorder
that traditionally was the leading cause of maternal
mortality.
The initial prenatal care visit involves taking a
thorough obstetric history; establishing the gestation-
al age of the fetus and the expected due date; assess-
ing the initial level of risk to ensure appropriate level
of treatment; initiating serial surveillance of fetal and
maternal biologic markers to ensure that the preg-
nancy is following a normal developmental trajectory
(e.g., physical exams, laboratory tests); and providing
general prenatal education and psychosocial support.
Subsequent visits involve continued serial surveil-
lance, psychosocial support, and childbirth and post-
partum education. Women with high-risk conditions,
such as diabetes, elevated blood pressure, sexually
transmitted diseases, and twins, may be followed
more closely or referred to high-risk prenatal care
specialists.
While the timing of prenatal care visits is well es-
tablished, the content of the visits continues to evolve.
New tests and procedures—such as alpha-
fetoprotein, amniocentesis, genetic testing, sexually
transmitted disease detection, and ultrasound—have
emerged and have increased the physician’s capacity
to monitor the health of the mother and the growing
fetus.
Although prenatal care as a formal medical ser-
vice began in the early 1900s as part of the newly
emerging obstetric profession’s efforts to reduce ma-
ternal mortality, more recently the primary focus of
prenatal care has increasingly shifted toward improv-
ing the health of the newborn. This shift has been ac-
companied by an expansion of prenatal health care
to address a broader, more comprehensive range of
health and social services that affect infant health. In
1965, as part of the War on Poverty, the federal Ma-
ternal and Infant Care project provided funds, for the
first time, for social workers, health educators, and
nutritionists to augment traditional medical services
at the then newly inaugurated community health cen-
ters. This broadening of prenatal care reflected rec-
ognition of the larger social health context of a
pregnancy, the limits of medical care alone to im-
prove birth outcomes, and the increased focus on in-
fant outcome.
Increasing Access to Prenatal Care
The 1980s saw a proliferation of public and pri-
vate efforts to increase access to comprehensive pre-
natal care, as health experts concluded that such care
was the public health solution for reducing the high
infant mortality rates in the United States and for de-
creasing racial disparities in poor birth outcomes.
The seminal 1985 Institute of Medicine report on
Preventing Low Birthweight (LBW), in particular,
strongly encouraged public efforts to increase the
availability and comprehensiveness of prenatal care
to reduce LBW. The report noted that prenatal care
was widely perceived to be effective at reducing LBW
and was cost effective ($3.38 saved for every dollar
spent); it envisioned a more comprehensive version
of prenatal care with strong psychosocial content.
Numerous federal, state, and philanthropic ef-
forts were undertaken in this period. The U.S. Na-
tional Commission to Prevent Infant Mortality was
established; the Healthy Mothers, Healthy Babies Co-
alition was formed; the March of Dimes initiated the
program Toward Improving the Outcome of Preg-
nancy; numerous state infant mortality commissions
were started; and several new federal infant mortality
reduction programs were undertaken (e.g., Healthy
Futures/Healthy Generations, Healthy Start Initia-
tive). A major federal report on the Content of Prena-
tal Care, published in 1989, also increased the focus
on psychosocial and comprehensive prenatal care.
The most significant achievement of this period
was the expansion of Medicaid in the late 1980s,
which increased eligibility for prenatal care services
by delinking Medicaid eligibility from welfare eligibil-
ity (specifically, the Aid to Families with Dependent
Children program), and fostered more comprehen-
sive prenatal care by allowing Medicaid to pay for nu-
merous nonmedical prenatal services. Medicaid now
could enroll and pay for the costs of prenatal care and
delivery of all poorer women (those with an income
of less than 185 percent of the poverty level), regard-
less of their marital status. Medicaid could also pay
for any case-management, home visitation, nutrition,
social work, and health education services that are
needed. By the early twenty-first century, Medicaid
was covering the costs of more than 40 percent of
births in the United States.
In 1980, the U.S. government set as one of its
1990 National Health objectives that 90 percent of all
pregnancies begin prenatal care in the first trimester.
By the end of the twentieth century, the United States
had still not reached this goal, and it therefore be-
came a Healthy People 2010 objective. According to
federal statistics from 1998, 82.8 percent of all moth-
ers began prenatal care in the first trimester. This fig-
ure rose steadily in 1990s from 75.8 percent, after a
decade-long period of no change. The increase in
early usage was most likely due to the numerous fed-
eral efforts initiated in the late 1980s. The figures also
revealed substantial disparities by race: 87.9 percent
of white mothers started prenatal care in the first tri-PRENATAL CARE 325