title: Inadequate prenatal care and its association with adverse pregnancy outcomes: a comparison of indices.
abstract: BACKGROUND
  The objectives of this study were to determine rates of prenatal care utilization in Winnipeg, Manitoba, Canada from 1991 to 2000; to compare two indices of prenatal care utilization in identifying the proportion of the population receiving inadequate prenatal care; to determine the association between inadequate prenatal care and adverse pregnancy outcomes (preterm birth, low birth weight [LBW], and small-for-gestational age [SGA]), using each of the indices; and, to assess whether or not, and to what extent, gestational age modifies this association.
  
  
  METHODS
  We conducted a population-based study of women having a hospital-based singleton live birth from 1991 to 2000 (N = 80,989). Data sources consisted of a linked mother-baby database and a physician claims file maintained by Manitoba Health. Rates of inadequate prenatal care were calculated using two indices, the R-GINDEX and the APNCU. Logistic regression analysis was used to determine the association between inadequate prenatal care and adverse pregnancy outcomes. Stratified analysis was then used to determine whether the association between inadequate prenatal care and LBW or SGA differed by gestational age.
  
  
  RESULTS
  Rates of inadequate/no prenatal care ranged from 8.3% using APNCU to 8.9% using R-GINDEX. The association between inadequate prenatal care and preterm birth and LBW varied depending on the index used, with adjusted odds ratios (AOR) ranging from 1.0 to 1.3. In contrast, both indices revealed the same strength of association of inadequate prenatal care with SGA (AOR 1.4). Both indices demonstrated heterogeneity (non-uniformity) across gestational age strata, indicating the presence of effect modification by gestational age.
  
  
  CONCLUSIONS
  Selection of a prenatal care utilization index requires careful consideration of its methodological underpinnings and limitations. The two indices compared in this study revealed different patterns of utilization of prenatal care, and should not be used interchangeably. Use of these indices to study the association between utilization of prenatal care and pregnancy outcomes affected by the duration of pregnancy should be approached cautiously.
authors.affiliation: Faculty of Nursing, Room 217 Helen Glass Centre for Nursing, University of Manitoba, Winnipeg, Manitoba, R3T 2N2 Canada. maureen_heaman@umanitoba.ca
authors.forename: Maureen I
authors.initials: MI
authors.lastname: Heaman
authors.forename: Christine V
authors.initials: CV
authors.lastname: Newburn-Cook
authors.forename: Chris G
authors.initials: CG
authors.lastname: Green
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Elliott
authors.forename: Michael E
authors.initials: ME
authors.lastname: Helewa
mesh_terms: D000328:Adult; D005260:Female; D005865:Gestational Age; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D016015:Logistic Models; D008350:Manitoba / Q000453:epidemiology; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology*; D047928:Premature Birth; D011295:Prenatal Care / Q000592:standards / Q000706:statistics & numerical data*