Prenatal Care

Prenatal Care

PRENATAL CARE: THE KEY TO REDUCING INFANTS DEATHS, Dixie Farley

Reprinted from the November 1985 issue of the FDA Consumer, a publication of the Food and Drug Administration.

(In the following article, how low birth weight and its countless lifethreatening complications can be prevented is examined. Because a baby’s health is affected by the mother’s health even before conception, the article stresses the need for mothers-to-be to adopt a healthy lifestyle before they become pregnant and then to seek prompt and thorough medical care when they find they are expecting.)

The U.S. infant mortality rate is too high, and one of the main reasons is that birth weights are too low.

Or, as the National Academy of Sciences’ Institute of Medicine put it in its 1985 report “Preventing Low Birthweight”: “Low birthweight is a major determinant of infant mortality in the United States.”

What’s more, the institute says low birth weight can be reduced or prevented by proper pre-pregnancy and prenatal care. (Low birth weight is defined as 5 1/2 pounds or less).

The infant mortality rate for 1984 is estimated at 10.6 per 1,000 live births. For 1983, it was 10.9 per 1,000 births. Those are improvements over 1978, when it was 13.8 per 1,000. But the 1983 and 1984 ratios still add up to more than 39,000 infant deaths each year.

Citing the 1978 figure in his 1980 report to the nation, the U.S. Surgeon General established a national public health policy of reducing the rate to no more than nine per 1,000 by 1990.

The Institute of Medicine says that recent declines in the mortality rate are attributed mainly to highly specialized newborn intensive-care units and the consequent survival of larger low-birth-weight babies. But roughly half of the very-low-birth-weight babies, who weigh about 3 1/4 pounds or less, do not survive. And although health risks decrease rapidly as birth weight increases (4- and 5-pound babies generally are expected to thrive), low- birth-weight babies are 40 times more likely than normal-birth-weight babies to die within the first 28 days of life, five times more likely to die later in the first year, and three times more likely to develop neurological problems, such as cerebral palsy and seizure disorders.

The woman who has a low-birth-weight baby is more likely to be black, poor, a smoker, under 17 or over 34, unmarried and under-educated. She may be addicted to alcohol or drugs. She probably practices poor nutrition. However, some women NOT in those population segments also have low-birth- weight babies, and other factors can be involved. In fact, the Institute of Medicine has identified 41 potential risk factors associated with low birth weight, from high blood pressure to exposure to toxic substances.

An overwhelming risk factor that is not yet well understood is race. Black women are about twice as likely as white women to have low-birth-weight babies. Some reasons that may partially explain this are known. For instance, proportionately more black than white mothers are teenagers, are slow to seek prenatal care, and have a low income and an education of less than 12 years–all factors associated with low birth weight. Yet these factors do not fully explain the birth-weight gap between blacks and whites.

The U.S. Assistant Secretary of Health reported in 1984 that even when several factors are controlled simultaneously,the gap remains. “The fact,” he said, “that mature, married, college-educated black women who received prenatal care are still twice as likely as their white counterparts to deliver a low-birth-weight infant indicates that the black-white disparity is not a simple phenomenon.” Researchers continue to study the problem.

An adverse outcome in a previous pregnancy–such as premature birth, malnutrition, multiple spontaneous abortions, stillbirth–may increase a woman’s chance of having a low-birth-weight baby in a later pregnancy. Complications arising during pregnancy that can add to the risk of low birth weight include infections, uterine bleeding, sustained high blood pressure, and detachment of the placenta.

To give her baby the best chance for a normal birth weight, it’s essential that a pregnant woman seek early and frequent prenatal care from a physician. In 1971, a study with a prematurity prevention program funded by the French government was implemented at Haguenau, France. Reported in “Pediatrics” in August 1985, the program demonstrated declines from 1971 to 1982 in low-birth-weight rates from 4.6 to 3.8 percent and in preterm-birth rates from 5.4 to 3.7 percent. In urging more vigorous efforts and greater government commitment in the United States to maternal and infant preventive health care, the Institute of Medicine pointed out that, for each dollar spent on prenatal care, there could be a savings of $3.38 on neonatal intensive care because of healthier babies.

Many private and public organizations are working to improve maternal and infant health. One such group is the Healthy Mothers, Healthy Babies Coalition, which was founded by the U.S. Department of Health and Human Services’ Public Health Service, the U.S. Department of Agriculture, the March of Dimes Birth Defects Foundation, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Nurses’ Association, and the National PTA. The coalition now comprises more than 75 national groups in more than 40 states. As part of this program, the Food and Drug Administration and other agencies offer print and broadcast public education materials. Functioning primarily through health departments, states are active in projects that range from loaning infant car seats, to promoting legislation, to offering speakers and conducting workshops. The national coalition, located in Washington, D.C., offers a directory of educational materials. A recurring theme of both local and national educational programs is how women can avoid the preventable risk factors linked to poor infant health and infant mortality, such as smoking, alcohol consumption, and drug abuse.

“Smoking,” the Surgeon General has said, “slows fetal growth, doubles the chance of low birthweight and increases the risk of stillbirth.” Unfortunately, an estimated 20 to 30 percent of the pregnant women in the United States smoke. And even after the baby is born, there are risks from the mother’s smoking. The National Institute of Child Health and Human Development has found that nicotine is secreted into breast milk and that large doses of it can inhibit milk production. Also, maternal smoking has been associated with sudden infant death syndrome–the sudden, unexpected and unexplained death of an apparently healthy infant.

For the most part, what the mother ingests, her baby does too. If it’s nutritious food, the baby should benefit. If it’s alcohol or another drug, the baby can suffer. In fact, between 1,800 and 3,600 babies are born each year in the United States with fetal alcohol syndrome, a pattern of birth defects caused directly by the mother’s drinking alcohol while she was pregnant. Babies with this syndrome are inappropriately small. Birth defects can include small brains, mental retardation, narrow eyes, short and upturned noses, and poor physical coordination. Another 36,000 newborns each year may be affected by a range of less severe alcohol-related effects. Among babies born to problem drinkers, as many as 29 per 1,000 have fetal alcohol syndrome. Because this condition is incurable and because scientists don’t know for certain how much alcohol is “safe,” the Surgeon General has advised women not to drink alcoholic beverages during pregnancy or when considering pregnancy.

Some medicines may harm the fetus. As soon as a woman suspects she may be pregnant, she should discuss with her physician any over-the-counter preparations (aspirin and cough syrups, for instance) or prescription drugs she may be taking. She should tell any physician or dentist who prescribes drugs for her that she is pregnant. Of course, regardless of whether a woman is pregnant, she should avoid illegal drugs, but this is especially true during pregnancy. The baby of a pregnant heroin user, for instance, can be born addicted and have withdrawal symptoms after birth. Even vitamins shouldn’t be self-prescribed, says the March of Dimes, because some can accumulate and harm an unborn baby.

There is no doubt that proper nutrition for the mother is good for the baby’s health. The effect of maternal nutrition on low birth weight is difficult to assess, however, because of the complicated relationship between poor nutrition and other risk factors and between a woman’s usual weight and her weight during pregnancy. In a 1984 study, Selma Taffel and Kenneth Keppel of the National Center for Health Statistics concluded that, even when many factors were controlled, including pre-pregnant weight, “Mothers who gained less than 21 pounds were still 2.3 times as likely to bear a low weight infant as mothers who gained at least 21 pounds.”

According the the American College of Obstetricians and Gynecologists, 22 to 27 pounds is an acceptable weight gain during pregnancy. And even if a woman is overweight before pregnancy, weight gain should not be rigidly restricted, as that could potentially harm fetal growth and development.

For poor women who are malnourished, supplemental food programs during and between pregnancies may help improve infant birth weight. One such program is the Special Supplemental Food Program for Women, Infants and Children (WIC), which also provides nutritional counseling. Because WIC prenatal participants must document that they are pregnant, the likelihood of an initial prenatal medical visit is increased. The program’s tie to prenatal care is further enhanced because WIC sites often are located at health centers with prenatal clinics.

It’s essential that health risks be identified as early as possible. Women considering pregnancy should seek medical advice about any existing health problems. Certain risk factors–such as diabetes mellitus, high blood pressure, and infectious diseases–warrant treatment before conception. A woman who is malnourished may be counseled by her physician to eat the right types of food to improve her nutritional status. Also, because German measles (rubella) can cause birth defects, women who didn’t get immunized during childhood should do so before becoming pregnant.

Proper, frequent medical care is important throughout the entire pregnancy. If a woman is diagnosed as being at risk for early labor, she may need more frequent checks by her physician to prevent premature birth. Some investigators are studying the possibility of monitoring pregnant women for early labor with a device that has a sensor located in an abdominal belt. Should the investigations prove successful, FDA could allow the device to be available for general use.

The risk factors associated with low birth weight and, thus, infant mortality point out the need for the woman who is or might be pregnant to adopt a healthy lifestyle, continue good health care during pregnancy, seek early and frequent prenatal care, and follow all treatments her physician prescribes.

From the March of Dimes Birth Defects Foundation, here are general guidelines for having a healthy pregnancy:

1. INFECTIOUS DISEASES. Before conception, get vaccinated against German measles. During pregnancy, don’t eat undercooked meat and don’t empty the cat’s litter box. Undercooked meat and cat feces may contain an organism that can cause toxoplasmosis, a disease that can cause birth defects. Tell you physician if you or your sexual partner have had genital herpes, chlamydia, gonorrhea, or other sexually transmitted diseases; and report any occurrence or recurrence of these diseases.
2. SMOKING. Don’t smoke. If you won’t quit, at least cut down; the negative effects of smoking on the fetus are linked directly to the number of cigarettes smoked.
3. DRUGS AND ALCOHOL. If you are pregnant or think you might be, tell any doctor or dentist who prescribes drugs for you. Check with your physician before taking ANY medicines. Don’t take illegal drugs. Don’t drink alcoholic beverages during pregnancy.
4. X-RAYS. If you are pregnant or think you might be, tell any doctor or dentist who prescribes X-rays for you. Abdominal, pelvic, lower back, and hip X-rays are of greatest concern because they expose the fetus to the direct X-ray beam. (FDA’s Center for Devices and Radiological Health, which regulates X-ray equipment, advises that, while no X-ray examination is completely risk-free, exams of the chest, head, teeth, hands or feet that are medically necessary are “safe enough,” provided a lead apron properly protects the abdomen. The center points out that it’s a good idea to take care of any needed dental work before becoming pregnant.)
5. PHYSICAL ACTIVITY. Unless your physician says otherwise, moderate exercise is healthy during pregnancy, but you shouldn’t overexert. Walking is especially good for digestion and circulation. If you’ve been physically active, consult your physician about what sports are safe to continue. Also, rest is essential. Get eight hours of sleep at night, and rest during the day.
6. SEX. Unless your physician says otherwise, sexual intercourse during a normal pregnancy is safe if no bleeding or uterine contractions occur afterwards.
7. DIET. Don’t try to lose weight, even if you were overweight before becoming pregnant. Drink several glasses of water each day. Eat four servings daily from each of the major food groups: dairy products, grains, meats and fish (proteins), and fruits and vegetables.
8. WARNING SIGNALS. If any of the warning signals listed below should appear, tell your physician immediately. (The health threats the signals may indicate are in parentheses.
   • Sudden increase in vaginal discharge or sudden gush of water from the vagina (ruptured membranes).
   • Vaginal bleeding (a separating or malpositioned placenta).
   • Chills, fever, or painful or burning urination (infection).
   • Rashes or lesions (sexually transmitted disease).
   • Severe or continuing nausea and vomiting, fainting spells, loss of consciousness, continuing or severe headache, blurred vision, spots before the eyes, or swelling of the face, hand, feet or ankles (high blood pressure).
   • Pelvic pressure, low dull backache, painless contractions, or sudden abdominal pain or cramping (premature labor).