The Future of Children, Princeton - Brookings: Providing research and analysis to promote effective policies and programs for children.

In 1932, Dr. F. Browne observed that "much of what passes under the guise of antenatal care is too irregular, too infrequent, too ill-organized and perfunctory to deserve the name and it can never accomplish anything . . . ."¹⁰⁹ There have been many improvements in prenatal care since then. Nevertheless, the most recent comprehensive review of the content of prenatal care concluded that, "to continue the process of refining the content of prenatal care to meet the objectives for pregnant woman, the infant, and the family, changes in public policy and prenatal care provider delivery of health care services must take place."⁷²

While lack of prenatal care has been highly associated with low birth weight in numerous studies, this relationship has been difficult to understand from a medical point of view as it has been observed that there is little done during the standard prenatal care visit that could be expected to reduce low birth weight.¹¹⁰ A more detailed examination of the available evidence and its limitations suggests that the potential direct impact of prenatal care on low birth weight may be far less than popularly assumed. On an individual level, there are three specific areas—for example, smoking cessation, nutrition of the malnourished, and medical care—where prenatal care can have an impact, particularly in reducing the number of small-for-gestational-age infants. Populationwide health promotion, social service, and case management approaches may offer further potential benefits, but data to link the provision of these services to reductions in low birth weight are lacking.

The very language of much of the research on the impact of prenatal care reflects a predisposition toward viewing prenatal care as a medical procedure to be doled out in units of service (the visit) or types of service. The use of visits as the measure of care is a natural extension of this point of view, which de-emphasizes the role of the mother, father, family, and the community in fostering a social and physical environment that enhances a positive pregnancy process. When an impression is created that prenatal care is a specific health care intervention that can be injected on a case-by-case basis to reduce low birth weight and other adverse pregnancy outcomes, populationwide and community-focused approaches may be overlooked. The ultimate success of prenatal care in reducing current low birth weight percentages in the United States may hinge on the development of a much broader and more unified conception of prenatal care than currently prevails. It has yet to be explored if interventions focused on building cohesive, functional communities can do as much or more to provide women effective social support and a caring, safe environment.

Numerous attempts have been made to estimate the cost-effectiveness of prenatal care services.^5,111 For each dollar spent on prenatal care, expected medical cost savings have been estimated to range from $2.57 to $3.38.^5,111 However, these estimates of the cost-effectiveness of prenatal care may be overstated given the unquantified differences in women who do and do not use prenatal care and the equivocal effectiveness of preterm prevention programs. Nevertheless, the long-term effects of comprehensive prenatal care on improving healthful behaviors and increasing use of preventive health care for infants and potentially all members of the family may be understated.⁷⁸ While considerable policy discourse has focused on the association of prenatal care with low birth weight, the benefits of prenatal care for maternal, infant, and family health should not be overlooked. To the extent that the value of prenatal care is narrowly viewed and promoted mainly in terms of its impact on low birth weight, its much broader impact and importance may be ignored.