Prenatal care

The WHO recommends that pregnant women should all receive at least eight antenatal visits to spot and treat problems and give immunizations. Although antenatal care is important to improve the health of both mother and baby, many women do not receive the recommended eight visits.^[4] There is little evidence behind the number of antenatal visits, pregnant women receive and what care and information is given at each visit.^[3] It has been suggested that women who have low-risk pregnancies should have fewer antenatal visits.^[3] However, when this was tested, women with fewer visits had babies who were much more likely to be admitted to neonatal intensive care and stay there for longer (though this could down to chance results).^[3] A 2015 Cochrane Review findings buttresses this notion, with evidence that in settings with limited resources, where the number of visits is already low, programmes of ANC with reduced visits are associated with an increase in perinatal mortality.^[3] Therefore, it is doubtful that the reduced visits model is ideal, even in low income countries (LICs), where pregnant women are already attending fewer appointments.^[2] Not only is visiting prenatal care early is highly recommended, but also a more flexible pathway allowing more visits, from the time a pregnant woman books for prenatal care, as it potentially enables more attention to those women who come late.^[2] Also, women who had fewer antenatal visits were not as satisfied with the care they received compared with women who had the standard number of visits.^[3]

A new alternative for some of the routine prenatal care visits is Telemedicine, which is an online route of performing these prenatal appointments, and became more of a standardized practice due to the COVID pandemic.^[5] Specifically, over half of pregnant women were afraid of stepping foot inside a hospital because of the risk of contracting the virus, so Telemedicine offered a way of contact that was not face to face, but would still get people the care they required.^[5] In depth obstetric examinations and blood work were not possible through Telemedicine, but other appointment tasks were possible, such as using personal devices to detect fetal heart rate, conducting maternal mental health consults, and general sharing of information between provider and patient.^[5] Overall, Telemedicine is seen as an improvement of prenatal care because it offers the potential for higher accessibility of care to marginalized groups.^[5]

There are many ways of changing health systems to help women access antenatal care, such as new health policies, educating health workers and health service re-organisation. Community interventions to help people change their behavior can also play a part. Examples of interventions are media campaigns reaching many people, enabling communities to take control of their own health, informative-education-communication interventions and financial incentives.^[6] A review looking at these interventions found that one intervention helps improve the number of women receiving antenatal care.^[6] However interventions used together may reduce baby deaths in pregnancy and early life, lower numbers of low birth weight babies born and improve numbers of women receiving antenatal care.^[6]

The World Health Organization (WHO) reported that in 2015 around 830 women died every day from problems in pregnancy and childbirth.^[7] Only 5 lived in high-income countries, and the rest lived in low-income countries.^[7]

A study examined the differences in early and low-weight birth deliveries between local and immigrant women and saw the difference caused by receiving prenatal care. The study, between 1997 and 2008, looked at 21,708 women giving birth in a region of Spain. The results indicated that very preterm birth (VPTB) and very low birth weight (VLBW) were much more common for immigrants than locals (Castelló et al., 2012). The study showed the importance of prenatal care and how universal prenatal care would help people of all origins get proper care before pregnancy/birth (Castelló et al., 2012).

Group prenatal care, in recent years, has been implemented in around 22 countries that are aiming to improve maternal care.^[8] This type of care offers a group of multiple pregnant people (typically around 8-12 of them that are in a similar stage of pregnancy) to see one or more providers simultaneously, along with following up every few weeks to these group appointments for continual care.^[8] Group antenatal care has been shown to be beneficial in ways of reduced cost, increased education, and increased sense of support.^[8] It has also been found that women who used group prenatal care visits were more likely to utilize family planning services after the baby has been delivered.^[8]

Midwife-led care for low-risk women is where a midwife team (and general practioner, if needed) leads the care a woman receives, and she does not usually see a specialist doctor in her pregnancy.^[9] Women with midwife-led pregnancies are more likely to give birth without being induced, instead they partake in natural labours. However, they are less likely to have their waters broken, an instrumental delivery, episiotomy or preterm birth.^[10] Around the same number of women in each group had a caesarean section.^[10]

At the initial antenatal care visit and with the aid of a special booking checklist the pregnant women become classified into either normal risk or high risk.^{[citation needed]}

In many countries, women are given a summary of their case notes including important background information about their pregnancy, such as their medical history, growth charts, and any scan reports.^[11] If the mother goes to a different hospital for care or to give birth the summary of her case notes can be used by the midwives and doctors until her hospital notes arrive.^[11]

A review looking into women keeping their own case notes shows they have more risk of having a caesarean section.^[11] However, the women reported feeling more in control having their notes, and would like to have them again in future pregnancies.^[11] 25% of women reported their hospital notes were lost in hospital, though none of the women forgot to take their own notes to any appointments.^[11]

Prenatal diagnosis or prenatal screening (note that "Prenatal Diagnosis" and "Prenatal Screening" refer to two different types of tests) is testing for diseases or conditions in a fetus or embryo before it is born. Obstetricians and midwives have the ability to monitor mother's health and prenatal development during pregnancy through series of regular check-ups.

Physical examinations generally consist of:

• Collection of the mother's (and general family) medical history
• Checking blood pressure of the mother
• Documentation of the mother's height and weight
• Pelvic exam
• Doppler fetal heart rate monitoring
• Blood and urine tests on the mother
• Discussion with caregiver

In some countries, such as the UK, the symphysial fundal height (SFH) is measured as part of antenatal appointments from 25 weeks gestation.^[12] (The SFH is measured from the woman's pubic bone to the top of the uterus.^[13] A review into this practice found only one piece of research, so there is not enough evidence to say whether measuring the SFH helps to detect small or large babies.^[14] As measuring the SFH is not costly and is used in many places, the review recommends carrying on this practice.^[14]

Growth charts are a way of detecting small babies by the measuring the SFH.^[15] There are two types of growth chart:

1. Population based chart, which shows a standard growth and size for each baby
2. Customized growth chart, which is calculated by looking at the mother's height and weight, along with the weights of their previous babies.^[15]

Examples of these growth charts are created by the World Health Organization and Centers for Disease Control and Prevention, which differ based on the sex of the infant, and can be found at: https://www.cdc.gov/growthcharts/who-charts.html A review looking into which of these charts detected small babies found that there is no good quality research to show which is best.^[15] More research is needed before the customized growth charts are recommended because they cost more money and take more time for the health care workers to make.^[15]

Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:^{[citation needed]}

• Diagnose pregnancy (uncommon)
• Check for the number of fetuses
• Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
• Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)
• Determine if an intrauterine growth retardation condition exists
• Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones)
• Check the amniotic fluid and umbilical cord for possible problems
• Determine due date and how far along the mother is based on measurements and relative developmental progress

Generally an ultrasound is ordered whenever an abnormality is suspected, or along a schedule similar to the following:^{[citation needed]}

• 7 weeks — confirm pregnancy, ensure that it's neither molar or ectopic, determine due date
• 13–14 weeks (some areas) — evaluate the possibility of Down syndrome
• 18–20 weeks — see the expanded list above
• 34 weeks (some areas) — evaluate size, verify placental position

A review looking at routine ultrasounds past 24 weeks found that there is no evidence to show any benefits to the mother or the baby.^[16]

Early scans mean that multiple pregnancies can be detected at an early stage of pregnancy^[17] and also gives more accurate due dates so that less women are induced who do not need to be.^[17]

Levels of feedback from the ultrasound can differ. High feedback is when the parents can see the screen and are given a detailed description of what they can see.^[18] Low feedback is when the findings are discussed at the end and the parents are given a picture of the ultrasound.^[18] The different ways of giving feedback affect how much the parents worry and the mother's health behaviour although there is not enough evidence to make clear conclusions.^[18] In a small study, mothers receiving high feedback were more likely to stop smoking and drinking alcohol however the quality of the study is low and more research is needed to say for certain which type of feedback is better.^[18]

Women experiencing a complicated pregnancy may have a test called a Doppler ultrasound to look at the blood flow to their unborn baby.^[19] This is performed to detect signs that the baby is not getting a normal blood flow and therefore is 'at risk'. A review looked at performing Doppler ultrasounds on all women even if they were at 'low risk' of having complications.^[19] The review found that routine Doppler ultrasounds may have reduced the number of preventable baby deaths but the evidence was not strong enough to recommend that they should be made routine for all pregnant women.^[19]

Prenatal care does not only apply to the parent carrying the baby, but it also applies to the sperm donor. Sperm effects the fetus' ability to grow properly, and proper nutrition is one of the main factors.^[20] For example, a zinc deficiency can lead to sperm deformations and reduced sperm motility which can cause infertility or improper fertilization of the egg, which has the potential to cause miscarriages or fetal deformities.^[20] Spina bifida, which is caused by a folic acid deficiency, is another example of the effects of prenatal malnutrition.^[21] Foods are typically fortified with folic acid in order to reduce this, but some flours like masa flour are not within those federal outlines,^[22] which is theorized to be why Hispanic women are most likely to have children with spina bifida.^[21] Because of all this, it is normally encouraged that women take a prenatal vitamin to prevent these fetal deformations and deficiency symptoms.^[23]

Research suggests that physical activity levels during pregnancy can impact delivery outcomes.^[24] A study examining the effects of exercise intensity on delivery type and risk of preterm birth found that varying levels of physical activity were linked to different pregnancy outcomes and associated risks.

Very low levels of physical activity are associated with an increased risk of both preterm and instrumental deliveries.^[25] Pregnant individuals with minimal activity may experience lower overall fitness and muscle tone, which can impact the body's ability to manage the physical demands of labor. Another study showed that individuals with higher handgrip strength are more likely to have a vaginal delivery, as greater muscle strength and endurance can support the labor process. In contrast, those who gained more weight during pregnancy or had larger arm and calf circumferences were more likely to undergo cesarean delivery, particularly in cases of nonprogressive labor.^[26]

Low levels of physical activity during pregnancy have been linked to a slightly elevated risk of cesarean delivery.^[25] Regular moderate exercise may help enhance pelvic muscle tone and cardiovascular fitness, potentially reducing the likelihood of cesarean intervention by supporting the body's endurance during labor.

For individuals seeking to engage in levels of vigorous or high intensity physical activity, one study did observe a slight increase in instrumental delivery, which involves the use of medical tools like forceps or vacuum devices.^[25] More intense physical activity may add extra demands on the body, potentially affecting labor progression and increasing the need for instrumental assistance.^{[citation needed]}

It is important for pregnant individuals to consult with their healthcare provider before beginning or adjusting exercise routines, particularly if they are new to regular physical activity or have any health conditions that may affect pregnancy.^{[citation needed]}

Proper prenatal care affects all women of various social backgrounds. While availability of such services have considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in both developing and developed nations, such as the US. Although women can benefit by utilizing prenatal care services, there exists various levels of health care accessibility between different demographics throughout the United States.^{[citation needed]}

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