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ARTICLE:
Zulfiqar A. Bhutta, Gary L. Darmstadt, Babar S. Hasan, and Rachel A. Haws
Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence
Pediatrics 2005; 115: 519-617 [Abstract] [Full text] [PDF]
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[Read P3R] Reviewing the role of prenatal care in infant health: Effectiveness versus efficacy studies.
George L Wehby   (4 April 2005)

Reviewing the role of prenatal care in infant health: Effectiveness versus efficacy studies. 4 April 2005
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George L Wehby,
Doctoral student
University of Iowa, Department of Health Management

Send letter to journal:
Re: Reviewing the role of prenatal care in infant health: Effectiveness versus efficacy studies.

george-wehby{at}uiowa.edu George L Wehby

To the Editor,

The review by Bhutta et al (2005) of community-based interventions targeting perinatal and neonatal health in developed countries provides a major contribution to increase awareness of researchers and policy makers about needs in this field. However, while we recognize that the authors focused mainly on evidence from randomized clinical trials (RCTs), we would like to point out that the discussion in this review may have benefited by incorporating several studies conducted by researchers in the health economics field that measure the impact of prenatal care on at- birth and neonatal health. While these observational studies are suboptimal to RCTs in establishing causality, the statistical models applied in these studies and the subject samples used, potentially provide estimates of the “effectiveness” (real world effect) of prenatal care, rather than estimates of “efficacy” usually obtained from RCTs. These studies (e.g. Rosenzweig and Schultz (1983), Corman et al (1987), Grossman and Joyce (1990), Frank et al (1992), Joyce (1994), Warner (1995)) have evaluated the impact of several measures of the quantity of prenatal care, including delay in initiating prenatal care, number of prenatal care visits, first semester initiation of prenatal care, and adequacy of prenatal care (Kessner index) on various infant health outcomes, including birth weight, gestational age, and intrauterine growth retardation.

The discussion in the supplement seemed to focus specifically on the optimal number of prenatal care visits. There is some research evidence, however, of a difference in the magnitude of the impact of delay in initiating prenatal care and of number of prenatal visits on infant health outcomes, with the former demonstrating a larger effect (e.g. Warner (1995)). Further, as a substantial proportion of women receive no prenatal care in developing communities, it seems of equal importance to discuss the impacts of delay in seeking prenatal care, compared to number of visits, as decreasing delay in seeking prenatal care may be a much easier target to achieve, as a first step, for health policies and programs in developing communities, rather than implementing and ensuring access to a pre-packaged prenatal care program.

While these studies are based on US samples, they provide useful results for achievable effectiveness of prenatal care in developing settings where health care technology usually lags far behind that of more developed communities. Finally, the authors mention that they could not cite a single source of objective evidence of the marginal impact of prenatal care on neonatal mortality (p 533). Corman et al (1987) provided estimates of proportion of births with prenatal care initiated in first trimester of pregnancy on neonatal mortality.

References:

Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence. Pediatrics. 2005;115:519- 617.

Corman H, Joyce TJ, Grossman M. Birth Outcome Production Function in the United States. The Journal of Human Resources. 1987;22:339-360.

Frank RG, Strobino DM, Salkever DS, Jackson CA. Updated Estimates of the Impact of Prenatal Care on Birthweight Outcomes by Race. The Journal of Human Resources. 1992;27:629-642.

Grossman M, Joyce TJ. Unobservables, Pregnancy Resolutions, and Birth Weight Production Functions in New York City. The Journal of Political Economy. 1990;98:983-1007.

Joyce TJ. Self-Selection, Prenatal Care, and Birthweight among Blacks, Whites, and Hispanics in New York City. The Journal of Human Resources, 1994;29:762-794.

Rosenzweig MR, Schultz TP. Estimating a Household Production Function: Heterogeneity, the Demand for Health Inputs, and Their Effects on Birth Weight. The Journal of Political Economy. 1983;91:723-746.

Warner GL. Prenatal Care Demand and Birthweight Production of Black Mothers. The American Economic Review. 1995;85:132-137.