Relationship between prenatal care and the outcome of pregnancy in low-risk pregnancies

doi:10.4236/ojog.2011.13019

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Open Journal of Obstetrics and Gynecology, 2011, 1, 109-112

doi:10.4236/ojog.2011.13019 Published Online September 2011 (http://www.SciRP.org/journal/ojog/

OJOG

Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJOG

Relationship between prenatal care and the outcome of

pregnancy in low-risk pregnancies

Tehereh Ashraf-Ganjoei1, Fatemeh Mirzaei2*, Fatemeh Anari-Dokht3

1Departement of obstetric & gynecology, Shahid Behshtei University, Tehran, Iran;

2Departement of obstetric & gynecology, Physiology research center, Kerman University, Kerman, Iran;

3Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran;

E-mail: *[email protected]

Received 30 May 2011; revised 22 August 2011; accepted 30 August 2011.

ABSTRACT

Introduction: This study was conducted to evaluate

the relationship between prenatal care and outcome

of pregnancy. Method: This is a cross-sectional study

on 210 pregnant women referring to Afzalipour Hos-

pital for their labor, consisting of 140 women with

adequate care and 70 with inadequate care. The out-

come of pregnancy for mother and newborn was

compared between the two groups. Data were an-

alyzed using SPSS software version 15. P value ≤ 0.05

was considered as significant and the power of statis-

tical test was 80%. Findings: The findings indicate

that the age of women with inadequate care was

lower compared to those receiving adequate care (p =

0.003). Furthermore, women with inadequate care

had lower education (p = 0.00007) and their prenatal

care started in more advanced gestational ages (p =

0.0003). Neonates born to women with inadequate

care tended to have lower birth weights (p = 0.05)

and higher rates of admission to NICU (p = 0.02).

Conclusion: Our findings indicate that women with

lower age and education received less prenatal care

and adequate prenatal care results in better birth

weights and decreased rate of admission in NICU.

Keywords: Prenatal Care; Maternal Complications;

Neonatal Complications

1. INTRODUCTION

Pregnancy constitutes one of the most sensitive periods

of a woman’s life, both physically and mentally [1]. Pre-

natal care has a history of more than 100 years; it is cur-

rently among the most important services provided by

the healthcare system and its use is gaining increasing

popularity [2]. The purpose of prenatal care is to deliver

a healthy newborn without jeopardizing the mother’s

health [3].Prenatal care and appropriate fetal monitoring

lead to timely interventions for prevention of preterm

labor and premature neonates. Moreover, prenatal care

may play a pivotal role to facilitate the pregnant woman

transferring to a properly-equipped labor center in a

timely manner [4]. If performed systematically and regu-

larly, it may considerably reduce mortality and compli-

cations in mothers and newborns [5]. Healthcare experts

have concluded that prenatal care is a cost-efficient in-

vestment. Therefore, it appears essential to provide ac-

cess to prenatal care from the early onset of pregnancy

[6]. However In a randomized clinical trial in the United

States in 1996, no considerable increase in preterm labor,

preeclampsia, C-section and low birth weight was ob-

served in women who had received less prenatal care [7].

Since there is no definite scientific basis for improving

the impact of prenatal care on outcome of pregnancy [1],

as well as the fact that certain risk factors, modifiable

through prenatal care, may be more frequent in develop-

ing countries where few studies have been conducted [8],

we undertook this study to determine the impact of pre-

natal care on maternal and fetal outcome.

2. METHODS

A cross-sectional study was performed on women refer-

ring to Afzalipour Hospital over a 1-year period from

2009 to 2010. Afzalipoor hospital Institutional Research

Review Board approved the study; furthermore, the

study was carried out under the Health Ministry Ethics

protocols.

Data were collected using data-recording sheets

through interviews and studies of medical files. All pa-

tients received adequate information regarding the study

and they all expressed their informed consent in written

forms.

Patients with a systemic disease, such as diabetes,

hypertension, epilepsy, lupus, cancer, renal disease or

any other systemic disease, as well as those considering

as cigarette smokers or narcotics users were excluded

T. Ashraf-Ganjoei et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 109-112

110

from the study. The number of prenatal cares for each

person was determined and women were categorized as

either receiving adequate care or inadequate care (de-

fined as less than 5 visits for gestational ages of less than

37 weeks or less than 8 visits for gestational ages of 37

weeks or beyond) [8]. The outcome of pregnancy, in-

cluding gestational age, birth weight, Apgar score, route

of delivery, need for NICU and occurrence of pree-

clampsia, gestational diabetes and postpartum hemor-

rhage were evaluated and compared between the two

groups.

Gestational age was determined by the patient’s last

menstrual period (LMP) and, when available, confirmed

by the first trimester ultrasound. The sample size was

determined based on previous studies and the study was

performed on 210 women referring to Afzalipour Hospi-

tal for their labor, consisting of 140 women with ade-

quate care and 70 with inadequate care.

After determination of descriptive statistics (central

and dispersion indices), data were analyzed using SPSS

software version 15. The Chisquare test was used to

compare the outcome of pregnancy between the two

groups. P value ≤ 0.05 was considered as significant and

the power of statistical test was 80%.

3. RESULTS

210 pregnant women composed of 140 receiving ade-

quate care and 70 receiving inadequate care were studied.

The overall mean age was 26.65 ± 0.4 years, with the

mean age of 24.9 ± 0.7 years for women receiving in-

adequate group and 27.52 ± 0.48 years for those receiv-

ing adequate care, indicating a significant difference (p =

0.003) (Table 1).

101 (48.09%) of women were educated less than a

high school diploma, 79 (37.61%) were high school gra-

duates and 30 (14.28%) had university level of education.

The relationship between education and type of prenatal

care is illustrated in Table 1.

193 (91.9%) of women were housewives, 13 (6.19%)

were clerks and 4 (1.9%) worked in the private sector. In

the group with adequate prenatal care, there were 126

(90%) housewives, 12 (8.57%) clerks and 2 (1.42%)

workers in private sector. In the group with inadequate

prenatal care, there were 67 (95.71%) housewives, 1

(1.42%) clerk, and 2 (2.58%) worked in the private sec-

tor (p = 0.4) (Table 1).

The mean gestational age of onset of cares was 12.59

± 1 weeks for the group with inadequate care and 8.39 ±

0.3 weeks for the other group (p = 0.05) (Table 1).

The mode of delivery in women consisted of 82

(39.04%) NVD and 128 (60.85%) Cesarean section. The

relationship between prenatal care and route of delivery

is showed in Table 2.

Regarding the gestational age, there were 51 (24.28%)

preterm, 130 (61.9%) term l, and 24 (11.42%) post-date

delivery. There were no significant differences among

two groups according to the gestational age at delivery

(P = 0.3).

The mean birth weight of all neonates was 2891.19 ±

45.07 g; the figures for the group with adequate care and

the group with inadequate care were 2958.21 ± 49.2 g

and 2757.14 ± 90.9 g, respectively, indicating a signifi-

cant difference (p = 0.05) (Table 2).

The mean 1st minute Apgar score was 8.76 ± 0.71 for

those with adequate care and 8.53 ± 0.17 for those with

inadequate care, indicating no significant difference (p =

0.2) (Table 2). The mean 5th minute Apgar scores for the

adequate and inadequate care groups were 9.81 ± 0.6

and 9.63 ± 0.16 respectively, indicating no significant

difference (p = 0.3) (Table 2).

29 (13.8%) newborns were admitted to NICU, con-

sisting of 15 (21.43%) in the inadequate care group and

14 (12.14%) in the adequate care group (Table 2).

There were 17 cases of gestational diabetes in our

study, with 15 (88.23%) of them in the adequate care

group and 2 (11.76%) in the inadequate care group (p =

0.05) (Table 3).

Early postpartum hemorrhage was observed in 3 (1.42%)

patients, all of them were in the adequate care group (p =

0.2). preeclampsia was observed in 18 (8.57%) of pa-

tients, including 11 (61.11%) in the adequate care group

and 7 (38.88%) in the inadequate care group (p = 0.6)

(Table 3).

4. DISCUSSION

Our findings indicate that the mean age and education of

women with inadequate prenatal care are lower com-

pared to those receiving adequate prenatal care. Accord-

ing to a study by Fekrat (1998), higher age and lower

education decreased the likelihood of referral for prena-

tal care [9]. Similarly, Kulmala et al. reported that illi-

teracy and lower levels of education are among major

reasons for not referring regularly for receiving prenatal

cares [10]. In our study, only 17 women were employed,

therefore, no significant relationship was found between

the employment of pregnant women and level of care

received. 14 of the employed women had received pre-

natal care and this indicates that employment may have a

positive effect on referral of pregnant women for prena-

tal care. In this study, the time of the initiation of prena-

tal care in women with adequate care was earlier; a

finding consistent with previous studies which indicated

that the most common cause of not referring for prenatal

care was unawareness of pregnancy. Regarding the ges-

tational age, the majority of women had term labor, fol-

lowed by preterm, post-date and post term labor, in de-

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111

OJOG

Table 1. Primary and Demographic characteristics of patients.

Variable Total Inadequate Care Adequate Care P Value

Maternal Age 26.54 ± 0.4 24.09 ± 0.7 27.52 ± 0.48 0.003

Maternal Education

Below High School Diploma 101 (48.1) 48 (68.5%) 53 (37.8%) 0.00007

High School Diploma 79 (37.6) 17 (35.4%) 62 (44.2%)

University 30 (14.3) 5 (7.1%) 25 (17.8%)

Maternal Occupation

housewives 193 (91.9%) 67 (95.71%) 126 (90%) 0.4

Clerk 13 (6.19%) 1 (1.42%) 12 (8.57%)

Private Sector 4 (1.9%) 2 (2.85%) 2 (1.42%)

Onset of Prenatal Care 9.97 ± 0.44 12.59 ± 1 8.39 ± 0.3 0.0003

Table 2. Comparison of outcome of pregnancy between adequate and inadequate care groups.

Outcome of Pregnancy

(Number/Percent) Total Inadequate Care Adequate Care P Value

Gestational Age 0.3

Preterm 51 (24.28%) 19 (27.14%) 32 (22.85%)

Term 130 (61.9%) 43 (61.4%) 87 (62.14%)

Post-date 24 (11.45%) 7 (10%) 17 (12.14%)

Postterm 5 (2.38) 1 (1.42%) 4 (2.85%)

Mode of Delivery 0.05

Repeated C/S 57 (27.14%) 16 (22.85%) 41 (29.28%)

C/S 71 (31.86%) 19 (27.15%) 52 (37.14%)

NVD 82 (39%) 35 (50%) 52 (37.14%)

Birth Weight 2891.19 ± 45.07 2757±90.9 2958.21 ± 49.2 0.05

1st minute Apgar 8.68 ± 0.07 8.53 ± 0.17 8.76 ± 0.76 0.2

5th minute Apgar 9.75 ± 0.69 9.63 ± 0.16 9.81 ± 0.06 0.3

NICU Admission 29 (13.80) 15 (21.43%) 14 (12.14%) 0.02

Table 3. Comparison of outcome or pregnancy between adequate and inadequate care groups.

Maternal Complications

(Number/Percent) Total Inadequate Care Adeguate Care P Value

Gestational Diabetes 17 (8%) 2 (2.85%) 15 (10.7%) 0.05

Early Postpartum Hemorrhage 3 (1.4%) 0 (0%) 3 (2.1%) 0.2

preeclampsia 18 (8.5%) 7 (10%) 11 (7.8%) 0.6

creasing order of frequency, indicating no significant

difference between the two groups. In study, Vintzileos et

al. (2002) delay in initiating prenatal care or waiving it

will be associated with complications of pregnancy in-

cluding premature rupture of membranes and post term

pregnancy [11]. Apparently, our study differs from the

latter as we have not exclusively dealt with preterm or

post term housewives women. No significant increase in

preterm labor in women who had received less prenatal

care (p = 0.19) has been reported by McDuffie et al. [7].

Regarding the route of delivery, the rate of vaginal de-

livery was lower in women who had received adequate

prenatal care which may be due to the more intense pre-

natal care in this group. In addition, in our study the rate

of previous C-section in women with adequate care was

higher that is a reason for their higher rate of C-section.

In a study in 1996, prenatal care did not affect the rate of

C-section considerably [7].

In our study, gestational diabetes was more frequent in

women with adequate prenatal care which may be due to

their higher rate of referral to prenatal care centers.

However, the rates of preeclampsia and early postpartum

T. Ashraf-Ganjoei et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 109-112

112

hemorrhage were not significantly different between the

two groups, although we did not compare the severity of

preeclampsia between the groups and it requires further

studies. Similarly, a study in 1996, the group with in-

adequate care did not have a significant increase in the

rate of preeclampsia (p = 0.74) [7].

In the present study, the birth weight of newborn with

adequate prenatal care was significantly higher. In a

study Hueston et al, indicated that the prevalence of low

birth weight was lower in newborns who had received

prenatal care from the first trimester compared to those

who had received the care in the second and third tri-

mester [5]. Goldani (2004) considers the impact of pre-

natal care on improving birth weight as the result of pre-

vention of newborns with SGA, better nutrition during

pregnancy and reduced cigarette smoking in women with

adequate prenatal care [8].

The present study reported that, the rate of NICU ad-

mission was lower in the group with adequate prenatal

care. Nevertheless, the 1st and 5th minute Apgar scores

were not significantly different between the two groups.

However, in the study by Boss et al, sufficient prenatal

care was associated with improved neonatal mortality,

birth weight, and Apgar scores [12].

5. ACKNOWLEDGEMENTS

The authors wish to express their gratitude to the Deputy of Research at

Kerman University of Medical Sciences for their sponsorship.

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