Prenatal Care Adequacy in the U.S.-Mexico Border Region: An Analysis of Spatial Distribution and the Factors Associated with Low or Late Utilization Open Access

Argotsinger, Brittany Claire (2012)

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An early, coordinated program of prenatal care is recognized in the obstetric community as an important means of preventing, screening for, and intervening to address adverse maternal and perinatal outcomes during pregnancy. In both the United States and Mexico, objectives have been established to increase the percent of women entering prenatal care in the first trimester. The United States has also established goals to increase the proportion of women receiving adequate levels of care. In recent decades, several indices have been developed to measure adequacy of prenatal care. The R-GINDEX considers timing of first prenatal visit and the number of expected visits a woman should receive given the total length of pregnancy gestation.


The current study offers a descriptive analysis of combined 2009 natality files from the 10 states located along the United States-Mexico border. A total of 1,376,123 singleton birth records were analyzed, including 1,023,767 U.S. resident births and 352,356 resident births. Border-specific analysis included 262,248 women residing in the 124 counties and municipalities along the U.S.-Mexico border. Regression analysis was conducted to evaluate maternal state of residence as a predictor of low-late utilization, after adjusting for other maternal characteristics available in the birth file.

Key Findings and Conclusions

Using an adaptation of the R-GINDEX to assess prenatal care adequacy, 46.4% of Mexican border residents received low or late prenatal care in 2009. In contrast, low-late utilization was observed among 16.9% of American residents in the region. Significant variation in adequacy was observed across states, with adjusted relative risk of low-late utilization ranging from 1.73 in Arizona to 3.33 in Coahuila, when compared to outcomes observed among California border residents. Findings suggest that the disparities may be driven by low numbers of prenatal care visits received by Mexican women. Similar rates of first trimester prenatal care entry and no utilization imply a need to further consider the utility of available instruments used to evaluate adequacy of prenatal care.

Table of Contents

Chapter 1: Introduction. 1

Background & Rationale. 1

Problem statement4

Research questions, purpose and aims. 4

Definition of Key Terms6

Chapter 2: Review of the Literature. 7

Effectiveness of prenatal care in preventing adverse pregnancy outcomes. 7

Standard clinical guidelines for prenatal care. 10

General and population-specific barriers to adequate PNC.. 12

Chapter 3: Data & Methods. 14

Population of Interest14

Sources of Data16




Chapter 4: Results. 26

Characteristics of the Population. 26

Overall Utilization of Prenatal Care in the Population. 30

Timing of Prenatal Care Entry. 32

Number of Prenatal Care Visits. 43

Low or Late Prenatal Care45

Spatial Analysis of Prenatal Care Distribution. 47

Bivariate Analysis and Relative Risk of Low-Late Utilization. 48

Adjusted Measures of Effect based on Multivariable Regression Modeling. 51

Chapter 5: Discussion, Conclusions & Public Health Implications 52

Current levels of prenatal care utilization in the U.S.-Mexico border region 52

Implications for variation across adequacy indicators--lessons for future measurement 56

Implications for binational practice standards & consensus building to improve continuity of care along the border 59

Study Limitations60

Recommendations for future research. 62

References. 64

Appendix A: Municipalities, Counties & Sister Cities of the U.S.-Mexico Border Region. 67

Appendix B: Spatial Mapping of Prenatal Care Indices in the U.S.-Mexico Border Region

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