Statement of Problem: Determining the impact of prenatal care on infant health is a central issue for both research and policy. The purpose of this study is to examine the relationship between the utilization of prenatal care and the outcome of neonatal brain injury in low birth weight infants. To date, this relationship has not been explored. Low birth weight (LBW) is a leading cause of neonatal and infant death and morbidity. Significant morbidity in LBW infants occurs due to neonatal brain injury. Increased survival of LBW infants has been accompanied by an increase in neonatal brain injury. Devastating long term sequelae of neonatal brain injury include cerebral palsy, vision loss, epilepsy, mental retardation, and school-age psychiatric disorders. The magnitude of the problem of neonatal brain injury is enormous.
Purpose: There is mounting evidence identifying the time of insult causing neonatal brain injury occurs in-utero, before labor ever begins, for some infants. It is therefore important to explore the relationship between utilization of prenatal care and neonatal brain injury to identify if prenatal care is a modifiable risk for neonatal brain injury in LBW infants.
Design: The study design was a nested case-control study from the Central New Jersey Neonatal Brain Hemorrhage Study.
Population: The original population-based cohort included 1105 newborns weighing 500 to 2000 grams at birth was enrolled from several central New Jersey hospitals from September 1984 to June 1987.
Methods: Cases (n=72) were selected based upon evidence of brain injury by four hours after birth based upon cranial ultrasound. Controls (n=412) were selected if there was no evidence of brain injury based upon all cranial ultrasounds. Serially-timed cranial ultrasounds were conducted at 4, 24 hours and 7 days of age on all infants. Extensive data were collected on each mother-infant pair by nurse interviewers. Mothers were interviewed soon after delivery to obtain information about prenatal care utilization. Data were abstracted from the mother's prenatal record and her labor and delivery record and the infant's hospital record.
Data Analysis: Prenatal care utilization was categorized three separate ways (Kessner Index, Kotelchuck Index, and yes/no to receipt of prenatal care). Univariable and multiple logistic regression analyses were performed.
Results: Birth weight was the most significant predictor of neonatal brain injury. No receipt of prenatal care was significant only for black infants. They were 2.11 more likely to have brain injury than non-black infants if their mothers received no prenatal care (95% CI: 1.20, 3.72). The Adequacy Indices (Kotelchuck and Kessner) did not predict brain injury. However, applying both indices to the same population of women yielded very different stories about the population's adequacy of prenatal care use: 14% scored inadequate on the Kessner Index, 22% scored inadequate on the Kotelchuck (c2=25.5, p=0.00).
Conclusions: Study findings reinforce the vulnerability of the lowest of the low birth infants for poor outcomes. Especially high risk are black infants born to mothers that received no prenatal care. The study also confirmed methodological variations and challenges when measuring and categorizing prenatal care use. Continued research with a broader framework is needed to better understand what about prenatal care makes the difference, rather than relying on the traditional Adequacy Indices.
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