1. Prenatal Care and Education Leonardo Villalpando-Ochoa Daniel Banuelos Jeanine Aguilar Erica Neuhaus Emerging Public Health Threats April 27, 2010

2. The Public Health threat at hand is that too few women with less than 12 years of education are receiving early (1-3 months) prenatal care.

3. National Data Population: Live births in the United States, 1995 - 2006. Source: United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data on CDC WONDER On-line Database

4. National Data Analysis Greater education level correlates to higher percentage of mothers receiving early prenatal care across all years 2003- 2005. There is a consistent difference of about 20% between the rates of women who receive early prenatal care and have 13+ years of education and women who have less than 12 years of education. For all years 2003-2005, the lowest adjusted rate was for mothers in the 15-19 years of age and 0-11 years education group, while the highest adjusted rate was in the 20-29 years of age and the 13+ years of education group.

5. State-Level Data California and Virginia Population: Live births in the United States, 1995 - 2006. Source: United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data on CDC WONDER On-line Database

6. State-Level Data Analysis CA had higher rates of early prenatal care across all education levels for each year 2003-2005. Both CA and VA showed the lowest levels of early prenatal care in women with less than 12 years education, and the highest levels of early prenatal care in women with 13+ years of education. Between 2003 and 2005, there is an overall decrease in the rate of women receiving early prenatal care if they have 12 years of education or less, but an increase in the rate of women with 13+ years of education. The crude rates of births in CA and VA have both dropped from 2003 to 2005 with 86.09% to 85.96% and 85.37% to 85.20% respectively.

7. County-Level Data Merced County and Fresno County Population: Live births in the United States, 1995 - 2006. Source: United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data on CDC WONDER On-line Database

8. County-Level Data Analysis The crude rates for attaining early prenatal care (1-3 Months) averaged over 2003-2005 is 64.09% in Merced County and 86.51% in Fresno County. Fresno County has a higher rate of early prenatal care in every education level, across all years. By 2005, women with 12 years of education in Merced County were receiving prenatal care at a lower rate than women with less than 12 years of education in Fresno County.

9. Contributors to lack of early prenatal care The main factor influencing whether or not a mother receives early prenatal care is the knowledge that such practice is necessary to ensure the health of both mother and child. Proper nutrition and healthy behaviors during pregnancy are subjects many young women are exposed to during their high school years. Whether information is gathered in a classroom or by social interactions, those who drop out before completing their high school degree are at a severe disadvantage. For example, they may not know that receiving early prenatal care can help prevent serious complications to both themselves and their unborn child. A lack of formal education may also result in fewer job opportunities and a relatively smaller income. Mothers with good jobs are more likely to have health insurance which covers the cost of early and adequate (within the first 3 months) prenatal care. Such a cost forms an effective barrier keeping the uneducated from seeking prenatal health. Stable jobs may also allow time off for the mother to attain prenatal care.

10. According to a study conducted by Hawaii’s Pregnancy Risk Assessment Monitoring System (PRAMS) In 2004-2006, common barriers preventing women from receiving early prenatal care were reported as: 12% Could not get leave from work 11% Didn't have child care 10% Their provider would not start care earlier 10% Didn't have QUEST card (Medicaid insurance) 7% Didn't have transportation 6% Wanted to keep their pregnancy secret 5% Were too busy 4% Could not get appt. 4% Did not have enough money *Source: Schempf A, Hayes D, Eshima M, Fuddy L. “Prenatal Care Fact Sheet.” Honolulu, HI: Hawai‘i Department of Health, Family Health Services Division; September 2008. **Note: All data obtained via Public Health Records’ birth certificates with a random sampling of about 2,000 women to survey them on their behavior during pregnancy.

11. Research Intervention In a non-randomized community intervention study monitoring the effects of different prenatal home visit strategies among poor Pregnant women. The study surveyed 339 women in Brazil 115 women selected for visits from community health agents 116 women selected for visits from volunteer leaders 108 women selected as control, receiving no visits from either group Pregnant women visited by community health agents began prenatal visits earlier than other groups, had more prenatal visits, lab tests, and clinical exams, and received more counseling on breastfeeding and iron supplementation. Pregnant women visited by volunteer groups noted increase in family participation, which helped in medical keeping medical appointments and supplementation. Conclusion: The study concludes that among all three groups Pregnant women visited by community health agents received adequate and early prenatal care than the other groups. It also concluded that home visits can improve the quality and early attainment of prenatal care for poor women and increase participation by family members (mainly husbands) during the pregnancy as opposed to control. CESAR, Juraci A. et al. Effects of different home visit strategies on prenatal care in Southern Brazil. Cad. Saúde Pública [online]. 2008, vol.24, n.11 [cited 2010-04-27], pp. 2614-2622. Available from:. ISSN 0102-311X. doi: 10.1590/S0102-311X2008001100016

12. Recommendation Based on finding indicated in the previous study, which show that offering prenatal care visitations will increase prenatal care usage and early access. To target Mothers with low education we recommend: – Implementation of a prenatal health visitations – Increase Prenatal Care clinic hours during week and weekends