Child Development

birthweight and infant mortality. More recent, rigor-
ous studies, however, have not generally demonstrat-
ed significant associations with improved birth
outcomes.

Several factors complicate this widely assumed
positive association. First, the association between
prenatal care visits and birth outcomes is not linear
but U-shaped. Both less (inadequate) care and more
(possibly medically needy) care are associated with in-
creased poor birth outcomes. Second, women who
participate in prenatal care enhancement programs
may be a more self-selected group of health-conscious
women, a factor that may be more important to im-
proving birth outcomes than their use of more en-
hanced prenatal care. Third, research has not
consistently demonstrated a strong impact of psycho-
social factors on LBW, prematurity, and infant mor-
tality. Much attention has shifted to the role of
infectious diseases, such as bacterial vaginosis, in oc-
currences of prematurity, an example of a biologic
factor in contrast to social factors. Fourth, almost all
the late twentieth century improvements in infant
mortality rates resulted from improvements in keep-
ing LBW babies alive through improved neonatal
care, not the prevention of low birthweight infants
(the presumed pathway of prenatal care). And finally,
there has been an increase in LBW and prematurity
rates in the United States, despite simultaneous broad
improvements in prenatal care overall. The policy
and programmatic enthusiasm of the 1980s and
1990s for access to comprehensive prenatal care to
address poor birth outcomes and racial disparities
had greatly diminished by the early twenty-first cen-
tury.

Trends in Prenatal Care

Several new trends in prenatal care efforts have
emerged. First, reflecting the popular aphorism that
‘‘you can’t solve a lifetime of ills in nine months of a
pregnancy,’’ there has been an increasing focus on
pre-conceptual care. Pre-conceptual care tries to de-
tect and treat key maternal health issues prior to the
beginning of the pregnancy. Examples include reduc-
tion of smoking, initiation of diabetes treatment, di-
etary improvement, and family planning. Pre-
conceptual care links prenatal/reproductive care to
the broader women’s health movement. Second,
there has been an increasing focus on providing spe-
cific ‘‘proven’’ prenatal care content rather than sim-
ply increasing the number of generic prenatal care
visits. In this way, prenatal care has increasingly fo-
cused on such areas as smoking reduction, substance
use reduction, diabetes treatment, WIC/nutrition sup-
plementation, folic acid consumption, genetic testing,
and HIV treatment. Third, there has been a further

expansion of prenatal care psychosocial content to

address newer and possibly more potent health risk

factors, such as spousal violence and environmental

risks. Finally, there has been a refocusing of prenatal

care to once again address issues of maternal health

and to not simply focus on birth outcomes (i.e., exam-

ining the impact of pregnancy on women’s health, not

simply the impact of women’s health on pregnancy

outcomes). Such an orientation focuses on prenatal to

postnatal continuities in maternal depression, obesi-

ty, hypertension, and diabetes, as well as postpartum

linkage to health services and satisfaction with care.

Beyond attempting to reduce the number of in-

fants born small and premature, U.S. public health

and clinical efforts to improve prenatal care usage

and content have not generally been directly linked

to child development programs. The federal funding

sources that address these two developmental periods

have been generally quite distinct. The temporal

focus of some of the relevant professions has not gen-

erally overlapped, which further adds to their discon-

tinuity. For example, obstetricians and public health

maternity workers may have little interaction with pe-

diatricians.

There are, however, increasing areas of overlap

between prenatal care and child development efforts.

There is increased recognition that many of the same

high-risk families are being seen in both public pre-

natal care and child development programs. Mater-

nal well-being (both physical and psychosocial) is

critical in both the prenatal and postnatal periods.

Comprehensive prenatal care now includes many of

the same interventions as child development: home

visitation, parent education, etc. In turn, the child de-

velopment community is increasingly recognizing the

importance of prenatal factors (including prenatal

care) on subsequent infant and child functioning.

There is a growing number of federal programs that

try to improve both the reproductive and child devel-

opmental domains, including Medicaid, WIC, Early

Intervention, and Title V. The newly revised Healthy

Start program (the largest federal initiative dedicated

to reproductive health) also has a focus on maternal

and infant health from pregnancy through the first

two years of an infant’s life.

Prenatal care remains primary care for women in

pregnancy. Its impact on both maternal health and

newborn health reflects the evolving knowledge about

its content and society’s ability to ensure universal ac-

cess.

See also: BIRTHWEIGHT; HEALTHY START; INFANT

MORTALITY; PREGNANCY

PRENATAL CARE 327