mester, compared to 73.3 percent of black, 74.3 per-
cent of Hispanic, and 83.1 percent of Asian mothers.
More comprehensive utilization measures, such
as the Kotelchuck Adequacy of Prenatal Care Utiliza-
tion (APNCU) Index, also use number of visits and
length of gestation, in addition to the timing of initial
care, to assess the ACOG prenatal care standards.
These indexes suggest an even more somber picture
of prenatal care usage in the United States. For exam-
ple, the APNCU Index reveals that only 74.3 percent
of pregnant women have adequate prenatal care, 13.8
percent intermediate care, and 16.9 percent inade-
quate care, with correspondingly worse figures for Af-
rican Americans, Hispanic Americans, and Asian
Americans. Interestingly, more than 31 percent of
U.S. women have more than the ACOG recommend-
ed number of visits, a percentage that increased sub-
stantially from the 24 percent level of 1990.
Barriers to the Use of Prenatal Care
A variety of barriers to the use of prenatal care
have been identified. In 1988 the Institute of Medi-
cine cited four groups of barriers: financial; inade-
quate systems capacity; organization, practices, and
atmosphere of prenatal services; and cultural/
personal. Financial barriers have largely, but not
completely, been addressed by the recent expansions
of Medicaid eligibility and by reforms in health insur-
ance, which have mandated pregnancy coverage. Im-
migration status and enrollment barriers, however,
There has been a recent refocusing of prenatal care to address issues of maternal health, such as diabetes,
obesity, and hypertension. For many women, regular exercise and careful dietary controls throughout
pregnancy have led to better overall maternal health. (Owen Franken/Corbis)still influence access to Medicaid coverage. Transpor-
tation remains a major structural barrier to care in
both urban and rural areas. Teens generally start pre-
natal care late. Organizational and personal factors,
such as disrespect by providers, lack of planned preg-
nancy, not valuing prenatal care, and fear of detec-
tion of drug usage, remain substantial barriers to
early and continuous prenatal care.
The content of care should be equal for all
women, regardless of the source of their care, but this
may not be the case. In general, prenatal care is more
comprehensive in public clinics (including that
among equally low-income women, public clinics
make more referrals to the federal Women, Infants,
and Children (WIC) nutrition program than private
doctor’s offices do). There is some evidence that pro-
viders offer different prenatal care content depend-
ing on the race and social class of their clients. And
white women participate in childbirth education
classes much more often than do African-American
women.The Relation between Prenatal Care and
Birth Outcomes
Although it is widely believed that prenatal care
is associated with better birth outcomes, the actual as-
sociation is more complex. Early case-control/
correlational research in the 1960s and 1970s gener-
ally showed a small positive association between
increased medical prenatal care and decreased low326 PRENATAL CARE