Prenatal care (PC), defined as one or more visits before admission to an obstetric unit for delivery [1], where pregnancy history, physical exam, appropriate laboratory studies, and imaging are obtained, is crucial for the wellbeing of newborns. Furthermore, it helps clinicians address preventable risk factors in the maternal history such as maternal substance use that contribute to poor health outcomes of infants [2] [3] [4].

Numerous studies have shown a strong association between a lack of prenatal care and an infant’s poor health outcome including low birth weight and prematurity [5] [6] [7] [8] [9]. However, a better understanding of how prenatal care relates to both social and medical wellbeing of a child would help us to understand obstacles to effective implementation. We aimed to show how a complete lack of prenatal care is associated with two types of determinants. The first determinant is social vulnerability, defined as certain conditions that impact an infant’s physical and mental wellbeing. Examples include maternal substance use and child protective service (CPS) involvement before discharge and a requirements for further social work or case management involvement at the birth hospital [10] [11] [12]. The second determinant is medical vulnerability, defined as identified conditions complicating the infant’s physical wellbeing later in life. For this, we specifically focused on neurodevelopmental outcomes, because poor neurodevelopmental outcomes tend to chronically derange a child’s long-term health [13]. We hypothesized that there would be a strong association between certain social and medical, and especially neurodevelopmental characteristics of mother-infant dyads and complete lack of PC.

For this study, patients admitted to an urban level III neonatal intensive care unit (NICU) and an affiliated well-baby nursery from surrounding communities where the percentage of mothers with no prenatal care is higher than for the country as a whole in 8 of its 13 jurisdictions were retrospectively revisited. Also by looking at an area where the population is particularly vulnerable, we aimed to identify some of the root causes behind a history of no prenatal care in order to suggest interventions that may serve to prevent poor neurodevelopmental outcomes.

Prenatal care is one of the most frequently used services in the United States healthcare system [14] [15] and is designed to ensure optimal maternal and fetal health [16] [17]. Prenatal care is especially important during high risk pregnancies, as it helps to establish early diagnosis and intervention for conditions that are known to present a risk to the health of the mother and the developing fetus [18] [19]. Compliance with prenatal care visits can also be indicative of appropriate parenting behaviors that include parental nurturance and readiness, both of which have been shown to be positively correlated with optimal neurodevelopmental outcomes after birth [20].

This study examined associations between prenatal care and neurodevelopmental outcomes, examined from both social and medical perspectives. Our purpose in this study is therefore two-fold. One, we attempted to compare two groups of mothers, one with prenatal care (PC) and another with complete absence of prenatal care (NPC), in order to identify specific challenges faced by NPC mothers. By better understanding such challenges, one can better provide them with opportunities to seek appropriate prenatal care by offering them both medical and non-medical assistance. Two, we attempted to show that there is a significant difference in the discharge diagnoses of infants born to mothers with and without prenatal care and that the impact of those diagnoses on neurodevelopmental outcome tends to be long lasting. Both NICU and well-baby cohorts were examined in order to demonstrate that the differences between PC and NPC groups persisted in both cohorts.

In our study, we were able to show that there was a statistically significant association between absence of prenatal care and the presence of selected social determinants such as a family’s demographic profile, the mother’s parity, a history intrauterine drug exposure and CPS involvement. In order to provide the social context for this study’s findings, the participating patients’ zip codes were compared and revealed that mothers who did not seek prenatal care were more concentrated in the areas that were further away from major acute care hospitals. These mothers also tended to be medically underserved and to be African American women of childbearing ages (15 - 44 y.o.) who earned a low income, indicating that there may be chronic mechanisms through which they are predisposed to high risk child birth. Beyerly et al. argued in their systemic reviews however that these vulnerable populations tended to show significant improvement in public health outcomes when appropriate interventions were adopted [19]. Thus our findings argue for implementation of relatively simple interventions for these mothers that would significantly improve outcomes for newborns including more readily available and easily accessible prenatal care. In our study, we also showed a strong association between a complete lack of prenatal care and a history of IUDE and CPS involvement. This is significant, because both IUDE and CPS involvement represent the lack of a family’s readiness for childcare and can chronically affect the child’s wellbeing [13]. Again, it is important to recognize that prenatal care can improve neurodevelopmental outcome by identifying this lack of readiness early in the pregnancy.

Our study also looked at an infants’ discharge diagnoses as surrogates for their medical vulnerability. Our findings suggested that the primary diagnoses of the infants in both the NICU and well-baby nursery were overall similar in NPC and PC cohorts, though more infants in the well-baby newborn nursery without prenatal care required escalation of care to the NICU due to clinical deterioration than their counterparts with prenatal care. Also notable was that birth weights were lower in the NPC group in both the NICU and newborn nursery, causing them to be more susceptible to medical complications. Also, the NPC group in the NICU showed a longer duration of respiratory support, a factor that contributed to a longer NICU stay (25.7 days in NPC group; 24.5 days in PC group) and chronic pulmonary conditions requiring further medical attention later in life [21]. When these chronic pulmonary conditions co-occur with low birth weight, they can significantly compromise the health of children later on in life. This is particularly significant, as most NPC mothers in this study reside in a jurisdiction where environmental conditions in some instances may further complicate pre-existing chronic lung conditions in their children [21] [22] [23].

Another aspect of medical vulnerability that we focused on were conditions that are known to have a high correlation with neurodevelopmental delay. These include 1) leaving the hospital with discharge diagnoses that include IVH, PVL, ROP, and failed routine audiology evaluation, and 2), a requirement for CNS medications (particularly antiepileptic medications, neurotoxic substances, and caffeine) while they were inpatients. In both the nursery and the NICU, the NPC group had a higher failure rate for initial audiology assessment, a finding that can predispose these infants to developmental language delays. Meanwhile, other examples of aforementioned neurological conditions showed very similar prevalence in the NPC and PC groups in both the NICU and the well-baby nursery. Though seemingly counterintuitive, this pattern is consistent with previous studies that show development of these pathologies is strongly correlated with the infant’s gestational age [21] [24], which is especially pertinent in the NICU cohort, and whose distribution was similar between NPC and PC groups. However, as mentioned earlier, this might imply that seeking and completing prenatal care appropriately can benefit the mother-infant dyad by lowering the maternal risks associated with pregnancy, potentially increasing the birth weight of the infant and lowering the risk for developing pulmonary complications [25] [26] [27]. With regard to a requirement for CNS medications, which in our study was exclusively caffeine, there was a higher prevalence of caffeine administration to the NPC babies in both the NICU and well-baby nursery.

In summary, our findings suggest that prenatal care can be revisited in the context of medical and social vulnerability. Understanding the relationship between lack of prenatal care and social determinants is important, because many families face numerous barriers to attending health care visits due to these social determinants and having a newborn can make these barriers more difficult to negotiate successfully [26] [27] [28] [29]. The relationship between completion of prenatal care and an infants’ medical vulnerability is also important, as the resulted poor health outcome for these infants can be chronic, especially when it involves neurodevelopmental delay and further burdens the family psychosocially. And finally, our study showed a strong association between lack of prenatal care and mothers from economically vulnerable populations with barriers to accessible healthcare services. We propose that prenatal care should continue to be a priority when considering public health policy and interventions that can significantly reduce neurodevelopmental morbidity.

Several limitations of this study warrant a mention. First of all, this study is mostly focused on poor birth outcomes in the newborn and is therefore limited when it comes to maternal factors such as a mothers’ education level. Also, we acknowledge that we conducted this study based on a relatively small cohort, especially those in the NICU, who were from an urban healthcare center serving a population with predominantly lower socioeconomic status. Therefore, findings should not be generalized to the general population. To address these limitations, additional research will need to be done with a larger and more heterogeneous population in order to strengthen our hypothesis.

The authors declare no conflicts of interest regarding the publication of this paper.

Lee-Park, J.J. and Valentine, T.L. (2019) Relationship of Prenatal Care to Poor Postnatal Outcomes in Infants Requiring Neurodevelopmental Assessment. Open Access Library Journal, 6: e5922. https://doi.org/10.4236/oalib.1105922