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Poor antenatal care and pregnancy outcome
European Journal of Obstetrics & Gynecology and Reproductive Biology, 50 ( 1993) 19 I- I96 0 1993 Elsevier Scientific Publishers Ireland Ltd. All rights reserved. 0028-2243/93/$06.00
191
EUROBS 01604
Poor antenatal care and pregnancy outcome BCatrice Blondel”, Pascale Dutilhb, Marcelle Delourb and Serge Uzanc ‘Epidemiological Research Unit on Women and Children’s Health, Villejuil; France bProteciion Maternelle et Infanrile, Paris, France ‘Departmen of Obstetrics and Gynaecology of Hlipital Tenon, Paris, France
Accepted for publication 26 March 1993
Summary Objectives: To characterize women receiving poor antenatal care and assess their perinatal risk. Design: Computerized data. Setting: Public hospital setting Paris (1987- 1990). Comparison with representative sample in Ile-de-France region (n = 6423). Methods: Poor attenders with less than 3 visits (n = 210) were compared with good attenders with 3 visits or more (n = 5631). Results: Poor attenders were younger and had higher rates of perinatal mortality (4.7%), preterm delivery (Odds ratio 5.2:4.3-6.3) and low birth weight (Odds ratio 4.6:3.7-5.6). Conclusion: Women with poor antenatal care have a greater risk for adverse pregnancy outcome. This risk cannot be attributed to unfavourable living conditions only. Antenatal care; Pregnancy outcome
Introduction
The French health care system is designed to give pregnant women easy access to health services. In some places, medical care is free, and more generally, measures are taken to minimize financial barriers and incite women to have at least minimum care with maternity benefits (FF907 month) [ 11. Nevertheless there are very great social inequalities in the use of health services, and some women receive no maternity benefits 121. Further both Correspondence to: Beatrice Blondel, INSERM - U 149, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France.
public maternity units and health centres which provide care for very poor populations or people without National Health Insurance point out that some women receive no antenatal care or have great difllculty in gaining access to antenatal clinics. The importance of lack of prenatal care and its relation with perinatal outcome is recognized in the United States [3-51. The situation is not so clear in Western European countries where it is often assumed that the absence of antenatal care is no longer an issue. To ascertain the social and demographic characteristics and pregnancy outcome of women who received little or no antenatal care, we studied
192
the population of women who were delivered at the Hopital Tenon, a public hospital located in a poor district of Paris. Population and Methods All women who were delivered at the Hopital Tenon between November 1987 and October 1990 were included. To assess antenatal care we considered the number of visits attended at the outpatient clinic or at any other setting, during which an obstetrical examination was performed by a medical doctor or midwife. Emergency visits followed by hospital
admission were included, except if they were followed by delivery within 24 h. Two groups of women were considered, according to the number of visits: the poor attenders who included all the women who had fewer than 3 visits and the good attenders who had at least 3. We compared these two groups for maternal characteristics, delivery and pregnancy outcome. As the Hopital Tenon is specialized in high risk pregnancies and admits a large proportion of women with complications, we also compared the poor attenders with the women who were delivered in the Ile-de-France region, where the Hopital Tenon is located. For this regional population, we
TABLE I Maternal characteristics of poor and good attenders in Hopital Tenon, and regional population Hopital Tenon Poor attenders < 3 visits (a) “/u
Good attenders z 3 visits (b) “/u
10.9 34.8 27.6 16.2 10.5 (210)
1.5 12.5 31.0 31.5 23.4 (5631)
Regional population (c) o/o a/b
a/c
Age at delivery (years)
c20 20-24 25-29 30-34 235
Number of previous pregnancies 0 34.3 l-3 43.3 r4 22.4 (210)
29.5 45.4 25.0 (5631)
24.5 25.0 30.0 19.6 (204)
52.8 15.2 9.8 22.2 (5631)
34.3
89.2 (5631)
2.4 19.7 38.3 26.8 12.8 (6325)
P < 0.001
P < 0.001
NS
NS
(a)
P < 0.001
-
(a)
P < 0.001
-
33.0 50.3 16.7 (6407)
Origin
French North African Black African Others
National Health Insurance coverage
(210) NS: not significant.
( ): number of cases. (a): not available.
193
used data from two sources. Perinatal mortality rate was obtained from vital statistics in 1989 [6]. Data on maternal characteristics, delivery and pregnancy outcome came from a sample of 6432 livebirths. In this sample all livebirths were collected during two weeks in 1989, one in Spring and one in Autumn [7]. As this data set included a very small number of variables, it was not always possible to compare data from the Hiipital Tenon with data for the Ile-de-France population. In the Hopital Tenon we also compared women who had 0 visit and women who had 1 or 2 in order to know whether the pregnancy outcome was worst in the former group than in the latter.
Data were analysed using the Epiinfo statistical package and by the X2-test and the Fisher’s exact test. To control for confounding factors, we used the Mantel-Haenszel X2-test. The relation between antenatal care, on the one hand, and preterm delivery or low birth weight, on the other, was estimated by odds ratios and the corresponding test-based confidence intervals [8]. Results Of the 5841 women who were delivered at the Hopital Tenon in the 3-year period studied, 210 (3.6%) were poor attenders (< 3 visits).
TABLE II Pregnancy outcome of poor and good attenders in Hopital Tenon and regional population Hopital Tenon Poor attenders <3 visits (a) ‘I;0
Good attenders 23 visits (b) u/o
Regional population (c) ‘K a/b
a/c
Perinalal mortality rate 4.7
0.9 (168327)*
(a)
(214)
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
Birth weight (g)
< 1500 1500-1999 2000-2499 2500-2999 3000-3499 13500
Gestational age (weeks) ~32 33-34
35-36 37-38 39-41 >41
6.5 5.1 10.7 25.6 34.0 18.1 (215)
9.0 I.4
10.8 20.8 54.2 3.8 (212)
1.7 2.0 6.6 23.8 38.5 27.2 (5771)
2.1 I.9
0.6 0.9 4.4 20.0 42.0 32.1 (6419)
0.7
6.2 26.2 61.1 2.5 (5774)
I.1 3.1 20.0 72.9 2.2 (6388)
10.2 (5714)
7.6 (6349)
Admission IO special care baby unil
22.0 (209) ( ): number of babies. (a): not available. *Vital statistics in 1989.
194
The poor attenders were significantly younger than the good attenders and also younger than the regional population sample (Table I). However, the number of previous pregnancies did not differ significantly among these three groups. Poor attenders included a small proportion of French women and a large proportion of women from North or Black Africa. Further, only 34.3% of the poor attenders were covered by National Health Insurance compared to 89.2% of the good attenders. The perinatal mortality rate was 4.7% in poor attenders compared with 0.9 in the regional population (Table II). The proportion of babies under TABLE III Maternal characteristics and pregnancy outcome of women who had 0 visit and women who had I or 2 in Hopital Tenon Number of visits 0
%
1-2 %
55.8 19.8 24.4 (86)
38.7 33.0 36.3 (124)
Number of previous pregnancies 0 29.1 l-3 46.5 24 24.4 (86)
37.9 41.1 21.0 (124)
NS
26.2 (84)
23.3 (120)
NS
20.9 (86)
43.5 (124)
P < 0.001
Perinatal mortality rate
4.6 (86)
4.7 (128)
NS
Birth weight < 2500 g
20.9 (86)
23.2 (129)
NS
19.3 (83)
22.5 (129)
NS
Age (years) <25 25-29 230
French origin
National Health Insurance coverage
Gestational age ~37 weeks
P < 0.001
2500 g was 22.3% in the poor attenders instead of 10.3% in the good attenders and 5.9% in the regional population. The proportions of babies born before 37 full weeks of gestation were 21.2, 10.2 and 4.9%, respectively in the 3 groups. When the regional population was taken as the reference group, the odds ratios were 4.6 (3.7-5.6) for birth weight under 2500 g in the poor attender group, and 5.2 (4.3-6.3) for preterm delivery. In the poor attender group, the proportion of babies admitted to special care baby unit was higher than in the two other groups. One-third of the babies in the poor attender group were admitted because of preterm birth and one-third because of diagnosed or suspected infection. The relation between antenatal care, on the one hand, and low birth weight, preterm delivery and admission to special care unit, on the other, was still significant after controlling for nationality and National Health Insurance coverage. Women who had no care were significantly younger than the women who had 1 or 2 visits (Table III). The proportion of women under 25 was 55.8 and 38.7, respectively in these two groups. The number of previous pregnancies and origin were similar in these two groups, nevertheless the proportion of women covered by National Health Insurance was significantly lower in the group who had no care than in the other group (20.9% vs. 43.5O%). Pregnancy outcome was very similar in women without care and women with 1 or 2 visits, and no significant difference was observed. The perinatal mortality rate was 4.6 and 4.7%, respectively in these two groups and the proportion of babies under 2500 g, 20.9% and 23.2%. Discussion Our study shows that in the sample of women who gave birth at the Hopital Tenon, those who had had fewer than 3 antenatal visits were exposed to a greater perinatal risk than those who had had three or more, or than the regional population. This difference persisted after controlling for maternal social characteristics. One possible explanation of the relationship we found between antenatal care and perinatal mor-
195
tality and morbidity might be that poor attenders chose to give birth at this maternity unit because of complications. However, this is very unlikely, for two reasons: firstly because poorer patients usually go to a public hospital as in most cases they only have to pay a very small contribution towards the cost of care, and secondly because a woman who, like 66% of the poor attenders in our study, has not booked in to a maternity unit has to give birth in the public hospital nearest to her home. We defined poor antenatal care according to the French regulation prevailing during the survey period. Today 7 visits are necessary to obtain the maternity benefits [9], but when the women in the present study gave birth, only 3 were required, the first during the first trimester of pregnancy, the second during the 6th month and the third during the 8th month. We considered that women were poor attenders if they had fewer than 3 visits, but we did not take into account the week of gestation at each visit because these data were not reliable. According to the schedule defined for the maternity benefits, some women may have less than 3 visits because of preterm delivery. Nevertheless during the 80s the usual practice was very early initial visit and one visit per month [IO,1 11. Thus women who had less than 3 visits by the sixth month could be considered as poor attenders. Our study was not restricted to women who had no antenatal care because we also wanted to take account of those who seek antenatal care because of complications. Among women who are reluctant to consult a medical doctor or cannot have visits, those who experience complications or illnesses are more likely to obtain antenatal care than similar women who remain healthy. Thus, the beneficial effect of antenatal care may be underestimated if women without care are compared to those receiving it. Nevertheless, in our population, the proportions of babies under 2500 g and of preterm babies did not differ significantly for women who had received no antenatal care at all and those who had attended fewer than 3 visits. The relationship between lack of antenatal care and increased perinatal mortality and morbidity has been recognized in various countries and populations [3,4,12-141. In these studies, the risk
of having a baby under 2500 g for a woman without antenatal care was very similar to the one we found here, since the corresponding odds ratios frequently ranged from 3 to 4. Nevertheless it is difficult to assess how far this risk is attributable to the lack of antenatal care and how far to other factors, mainly the living conditions of poor attenders. This is because those women belong to a very underprivileged population and it is not easy to obtain an appropriate index of their social environment. In the studies, various indexes were used to control for this risk factor. Women without antenatal care were observed to have higher risk of having a low birth weight baby than other women, after adjusting for the usual social and demographic risk factors, such as maternal age or educational level [3,4] or after taking account of indexes of an underprivileged situation, such as in the present study, the absence of National Health Insurance coverage, and in another study, refugee status, or financial difficulties or hardship during pregnancy [ 151. Another way of adjusting for social stratum and lifestyle is to study women who have had no antenatal care because health services were not available to them. Thus Moore et al. [ 161 compared women who had been given care within the framework of a perinatal program and women who could not be enrolled because of the program’s limited resources. They found that the average number of antenatal visits was 12 in the former group and 1 in the latter and that the proportions of low birth weight babies were 6 and 21%, respectively in the two groups. This is therefore not possible to attribute the high perinatal risk for women with poor care to their social situation only. Some perinatal deaths and severe complications after birth could be avoided by adequate antenatal care. The measures which should be taken are numerous. However great the resources devoted to improving access to health services, there will always be women who will not receive antenatal care, because they deny their pregnancy or refuse to have any contact with doctors. Nevertheless, in Paris, it seems that lack of antenatal care is mainly due to financial or administrative barriers, since two-thirds of the poor attenders in our study had no Health Insurance coverage. This situation is
196
unexpected, since antenatal clinics are entitled to provide free care to pregnant women whether or not they are insured and whether their status in France is legal or illegal. Our results concerning insurance coverage raise questions regarding access to health services in Paris. Poor antenatal care is not peculiar to the district where the Hopital Tenon is located. It is estimated, from a representative sample of live births in France, that 0.5% of pregnant women have no antenatal visit (Epidemiological Research Unit on Women and Children’s Health, unpublished data), and in several other European countries, this percentage is higher [ 171. This situation shows that efforts should be devoted to identifying the women most likely to have no antenatal care, and to ensuring that existing health services are available for socially underprivileged women.
8 9
10
11
12
Acknowledgements 13
We wish to thank Maryvonne Miguet for her help in data analysis. We are also grateful for Gerard Breart and Monique Kaminski for their comments. References 1
2
3 4
Garcia J, Blonde1 B. Saurel-Cubizolles MJ. The needs of childbearing families: social policies and the organization of health care. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989;205-220. Blonde1 B, Saurel-Cubizolles MJ. An indicator of adverse pregnancy outcome: not receiving maternity benefits. J Epidemiol Community Health 1991;45:211-215. Eisner V, Brazie JV, Pratt MW, Hexter AC. The risk of low birth weight. Am J Public Health 1979;69:887-893. Greenberg RS. The impact of prenatal care in different social groups. Am J Obstet Gynecol 1983;145:797-801.
14
15
16
17
Brown SS, ed. Prenatal care. Reaching mothers, reaching infants. Washington: National Academy Press, 1988. Couet C, Court Y. La situation demographique en 1989. INSEE R&mats, Demographic-Societe 1991;l l-12:210. B&art G, Blonde1 B, Kaminski M et al. Mortaliti et morbidite ptrinatales en France. In: Tournaire M, ed. Mises a Jour en Gynecologie et Obstitrique. Paris: College National des Gyntcologues et Obstetriciens FrancaisVigot, 1991;175-214. Miettinen OS. Estimability and estimation in case-referent studies. Am J Epidemiol 1976;103:226-235. D&ret no. 92-143 du 14 F&tier 1992 relatif aux examens obligatoires prtnuptiaux, pre- et postnatals. J Off 1992;124:2505-2506. Rumeau-Rouquette C, du Mazaubrun C, Rabarison Y, eds. Naitre en France. 10 ans d’tvolution. Paris: INSERM-Doin, 1984. Buekens P, Kotelchuck M, Blonde1 B, Kristensen FB, Chen J, Masuy-Strobant G. Is prenatal care utilization greater in Europe than the United States? Am J Public Health 1993;83:31-36. Keeping JD, Chang AMZ, Morrison J, Esler EJ. Poor antenatal attendance and obstetric performance. Aust NZ J Obstet Gynaecol 1980;20:139-143. Kaunitz AM, Spence C, Danielson TS, Rochat RW, Grimes DA. Perinatal and maternal mortality in a religious group avoiding obstetric care. Am J Obstet Gynecol 1984;150:826-831. Insler V, Larholt ZJ, Baly R, Bar-David G, Meizner I, Karplus M, Stone D. The impact of prenatal care on the outcome of pregnancy. Em J Obstet Gynecol Reprod Biol 1986;23:21l-223. Binsacca DB, Ellis J, Martin DG, Petitti DB. Factors associated with low birth weight in an inner-city population: the role of financial problems. Am J Public Health 1987;77:505-506. Moore TR, Origiel W, Key TC, Resnik R. The perinatal and economic impact of prenatal care in a lowsocioeconomic population. Am J Obstet Gynecol 1986;154:29-33. Buekens P. Variations in provision and uptake of antenatal care. Bail&e’s Clin Obstet Gynaecol 1990;4: 187-205.
191
EUROBS 01604
Poor antenatal care and pregnancy outcome BCatrice Blondel”, Pascale Dutilhb, Marcelle Delourb and Serge Uzanc ‘Epidemiological Research Unit on Women and Children’s Health, Villejuil; France bProteciion Maternelle et Infanrile, Paris, France ‘Departmen of Obstetrics and Gynaecology of Hlipital Tenon, Paris, France
Accepted for publication 26 March 1993
Summary Objectives: To characterize women receiving poor antenatal care and assess their perinatal risk. Design: Computerized data. Setting: Public hospital setting Paris (1987- 1990). Comparison with representative sample in Ile-de-France region (n = 6423). Methods: Poor attenders with less than 3 visits (n = 210) were compared with good attenders with 3 visits or more (n = 5631). Results: Poor attenders were younger and had higher rates of perinatal mortality (4.7%), preterm delivery (Odds ratio 5.2:4.3-6.3) and low birth weight (Odds ratio 4.6:3.7-5.6). Conclusion: Women with poor antenatal care have a greater risk for adverse pregnancy outcome. This risk cannot be attributed to unfavourable living conditions only. Antenatal care; Pregnancy outcome
Introduction
The French health care system is designed to give pregnant women easy access to health services. In some places, medical care is free, and more generally, measures are taken to minimize financial barriers and incite women to have at least minimum care with maternity benefits (FF907 month) [ 11. Nevertheless there are very great social inequalities in the use of health services, and some women receive no maternity benefits 121. Further both Correspondence to: Beatrice Blondel, INSERM - U 149, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France.
public maternity units and health centres which provide care for very poor populations or people without National Health Insurance point out that some women receive no antenatal care or have great difllculty in gaining access to antenatal clinics. The importance of lack of prenatal care and its relation with perinatal outcome is recognized in the United States [3-51. The situation is not so clear in Western European countries where it is often assumed that the absence of antenatal care is no longer an issue. To ascertain the social and demographic characteristics and pregnancy outcome of women who received little or no antenatal care, we studied
192
the population of women who were delivered at the Hopital Tenon, a public hospital located in a poor district of Paris. Population and Methods All women who were delivered at the Hopital Tenon between November 1987 and October 1990 were included. To assess antenatal care we considered the number of visits attended at the outpatient clinic or at any other setting, during which an obstetrical examination was performed by a medical doctor or midwife. Emergency visits followed by hospital
admission were included, except if they were followed by delivery within 24 h. Two groups of women were considered, according to the number of visits: the poor attenders who included all the women who had fewer than 3 visits and the good attenders who had at least 3. We compared these two groups for maternal characteristics, delivery and pregnancy outcome. As the Hopital Tenon is specialized in high risk pregnancies and admits a large proportion of women with complications, we also compared the poor attenders with the women who were delivered in the Ile-de-France region, where the Hopital Tenon is located. For this regional population, we
TABLE I Maternal characteristics of poor and good attenders in Hopital Tenon, and regional population Hopital Tenon Poor attenders < 3 visits (a) “/u
Good attenders z 3 visits (b) “/u
10.9 34.8 27.6 16.2 10.5 (210)
1.5 12.5 31.0 31.5 23.4 (5631)
Regional population (c) o/o a/b
a/c
Age at delivery (years)
c20 20-24 25-29 30-34 235
Number of previous pregnancies 0 34.3 l-3 43.3 r4 22.4 (210)
29.5 45.4 25.0 (5631)
24.5 25.0 30.0 19.6 (204)
52.8 15.2 9.8 22.2 (5631)
34.3
89.2 (5631)
2.4 19.7 38.3 26.8 12.8 (6325)
P < 0.001
P < 0.001
NS
NS
(a)
P < 0.001
-
(a)
P < 0.001
-
33.0 50.3 16.7 (6407)
Origin
French North African Black African Others
National Health Insurance coverage
(210) NS: not significant.
( ): number of cases. (a): not available.
193
used data from two sources. Perinatal mortality rate was obtained from vital statistics in 1989 [6]. Data on maternal characteristics, delivery and pregnancy outcome came from a sample of 6432 livebirths. In this sample all livebirths were collected during two weeks in 1989, one in Spring and one in Autumn [7]. As this data set included a very small number of variables, it was not always possible to compare data from the Hiipital Tenon with data for the Ile-de-France population. In the Hopital Tenon we also compared women who had 0 visit and women who had 1 or 2 in order to know whether the pregnancy outcome was worst in the former group than in the latter.
Data were analysed using the Epiinfo statistical package and by the X2-test and the Fisher’s exact test. To control for confounding factors, we used the Mantel-Haenszel X2-test. The relation between antenatal care, on the one hand, and preterm delivery or low birth weight, on the other, was estimated by odds ratios and the corresponding test-based confidence intervals [8]. Results Of the 5841 women who were delivered at the Hopital Tenon in the 3-year period studied, 210 (3.6%) were poor attenders (< 3 visits).
TABLE II Pregnancy outcome of poor and good attenders in Hopital Tenon and regional population Hopital Tenon Poor attenders <3 visits (a) ‘I;0
Good attenders 23 visits (b) u/o
Regional population (c) ‘K a/b
a/c
Perinalal mortality rate 4.7
0.9 (168327)*
(a)
(214)
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
Birth weight (g)
< 1500 1500-1999 2000-2499 2500-2999 3000-3499 13500
Gestational age (weeks) ~32 33-34
35-36 37-38 39-41 >41
6.5 5.1 10.7 25.6 34.0 18.1 (215)
9.0 I.4
10.8 20.8 54.2 3.8 (212)
1.7 2.0 6.6 23.8 38.5 27.2 (5771)
2.1 I.9
0.6 0.9 4.4 20.0 42.0 32.1 (6419)
0.7
6.2 26.2 61.1 2.5 (5774)
I.1 3.1 20.0 72.9 2.2 (6388)
10.2 (5714)
7.6 (6349)
Admission IO special care baby unil
22.0 (209) ( ): number of babies. (a): not available. *Vital statistics in 1989.
194
The poor attenders were significantly younger than the good attenders and also younger than the regional population sample (Table I). However, the number of previous pregnancies did not differ significantly among these three groups. Poor attenders included a small proportion of French women and a large proportion of women from North or Black Africa. Further, only 34.3% of the poor attenders were covered by National Health Insurance compared to 89.2% of the good attenders. The perinatal mortality rate was 4.7% in poor attenders compared with 0.9 in the regional population (Table II). The proportion of babies under TABLE III Maternal characteristics and pregnancy outcome of women who had 0 visit and women who had I or 2 in Hopital Tenon Number of visits 0
%
1-2 %
55.8 19.8 24.4 (86)
38.7 33.0 36.3 (124)
Number of previous pregnancies 0 29.1 l-3 46.5 24 24.4 (86)
37.9 41.1 21.0 (124)
NS
26.2 (84)
23.3 (120)
NS
20.9 (86)
43.5 (124)
P < 0.001
Perinatal mortality rate
4.6 (86)
4.7 (128)
NS
Birth weight < 2500 g
20.9 (86)
23.2 (129)
NS
19.3 (83)
22.5 (129)
NS
Age (years) <25 25-29 230
French origin
National Health Insurance coverage
Gestational age ~37 weeks
P < 0.001
2500 g was 22.3% in the poor attenders instead of 10.3% in the good attenders and 5.9% in the regional population. The proportions of babies born before 37 full weeks of gestation were 21.2, 10.2 and 4.9%, respectively in the 3 groups. When the regional population was taken as the reference group, the odds ratios were 4.6 (3.7-5.6) for birth weight under 2500 g in the poor attender group, and 5.2 (4.3-6.3) for preterm delivery. In the poor attender group, the proportion of babies admitted to special care baby unit was higher than in the two other groups. One-third of the babies in the poor attender group were admitted because of preterm birth and one-third because of diagnosed or suspected infection. The relation between antenatal care, on the one hand, and low birth weight, preterm delivery and admission to special care unit, on the other, was still significant after controlling for nationality and National Health Insurance coverage. Women who had no care were significantly younger than the women who had 1 or 2 visits (Table III). The proportion of women under 25 was 55.8 and 38.7, respectively in these two groups. The number of previous pregnancies and origin were similar in these two groups, nevertheless the proportion of women covered by National Health Insurance was significantly lower in the group who had no care than in the other group (20.9% vs. 43.5O%). Pregnancy outcome was very similar in women without care and women with 1 or 2 visits, and no significant difference was observed. The perinatal mortality rate was 4.6 and 4.7%, respectively in these two groups and the proportion of babies under 2500 g, 20.9% and 23.2%. Discussion Our study shows that in the sample of women who gave birth at the Hopital Tenon, those who had had fewer than 3 antenatal visits were exposed to a greater perinatal risk than those who had had three or more, or than the regional population. This difference persisted after controlling for maternal social characteristics. One possible explanation of the relationship we found between antenatal care and perinatal mor-
195
tality and morbidity might be that poor attenders chose to give birth at this maternity unit because of complications. However, this is very unlikely, for two reasons: firstly because poorer patients usually go to a public hospital as in most cases they only have to pay a very small contribution towards the cost of care, and secondly because a woman who, like 66% of the poor attenders in our study, has not booked in to a maternity unit has to give birth in the public hospital nearest to her home. We defined poor antenatal care according to the French regulation prevailing during the survey period. Today 7 visits are necessary to obtain the maternity benefits [9], but when the women in the present study gave birth, only 3 were required, the first during the first trimester of pregnancy, the second during the 6th month and the third during the 8th month. We considered that women were poor attenders if they had fewer than 3 visits, but we did not take into account the week of gestation at each visit because these data were not reliable. According to the schedule defined for the maternity benefits, some women may have less than 3 visits because of preterm delivery. Nevertheless during the 80s the usual practice was very early initial visit and one visit per month [IO,1 11. Thus women who had less than 3 visits by the sixth month could be considered as poor attenders. Our study was not restricted to women who had no antenatal care because we also wanted to take account of those who seek antenatal care because of complications. Among women who are reluctant to consult a medical doctor or cannot have visits, those who experience complications or illnesses are more likely to obtain antenatal care than similar women who remain healthy. Thus, the beneficial effect of antenatal care may be underestimated if women without care are compared to those receiving it. Nevertheless, in our population, the proportions of babies under 2500 g and of preterm babies did not differ significantly for women who had received no antenatal care at all and those who had attended fewer than 3 visits. The relationship between lack of antenatal care and increased perinatal mortality and morbidity has been recognized in various countries and populations [3,4,12-141. In these studies, the risk
of having a baby under 2500 g for a woman without antenatal care was very similar to the one we found here, since the corresponding odds ratios frequently ranged from 3 to 4. Nevertheless it is difficult to assess how far this risk is attributable to the lack of antenatal care and how far to other factors, mainly the living conditions of poor attenders. This is because those women belong to a very underprivileged population and it is not easy to obtain an appropriate index of their social environment. In the studies, various indexes were used to control for this risk factor. Women without antenatal care were observed to have higher risk of having a low birth weight baby than other women, after adjusting for the usual social and demographic risk factors, such as maternal age or educational level [3,4] or after taking account of indexes of an underprivileged situation, such as in the present study, the absence of National Health Insurance coverage, and in another study, refugee status, or financial difficulties or hardship during pregnancy [ 151. Another way of adjusting for social stratum and lifestyle is to study women who have had no antenatal care because health services were not available to them. Thus Moore et al. [ 161 compared women who had been given care within the framework of a perinatal program and women who could not be enrolled because of the program’s limited resources. They found that the average number of antenatal visits was 12 in the former group and 1 in the latter and that the proportions of low birth weight babies were 6 and 21%, respectively in the two groups. This is therefore not possible to attribute the high perinatal risk for women with poor care to their social situation only. Some perinatal deaths and severe complications after birth could be avoided by adequate antenatal care. The measures which should be taken are numerous. However great the resources devoted to improving access to health services, there will always be women who will not receive antenatal care, because they deny their pregnancy or refuse to have any contact with doctors. Nevertheless, in Paris, it seems that lack of antenatal care is mainly due to financial or administrative barriers, since two-thirds of the poor attenders in our study had no Health Insurance coverage. This situation is
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unexpected, since antenatal clinics are entitled to provide free care to pregnant women whether or not they are insured and whether their status in France is legal or illegal. Our results concerning insurance coverage raise questions regarding access to health services in Paris. Poor antenatal care is not peculiar to the district where the Hopital Tenon is located. It is estimated, from a representative sample of live births in France, that 0.5% of pregnant women have no antenatal visit (Epidemiological Research Unit on Women and Children’s Health, unpublished data), and in several other European countries, this percentage is higher [ 171. This situation shows that efforts should be devoted to identifying the women most likely to have no antenatal care, and to ensuring that existing health services are available for socially underprivileged women.
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Acknowledgements 13
We wish to thank Maryvonne Miguet for her help in data analysis. We are also grateful for Gerard Breart and Monique Kaminski for their comments. References 1
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