[Utilisation gradients in prenatal care prompt further development of the prevention concept].
OBJECTIVE
Deliveries are the most common inpatient treatment for women in Germany. The pregnant women, their personal environment and society have an interest in and right of information about health care for expectant mothers and newborns. Analysis of perinatal data should show whether differences exist in the health chances of pregnant women from different social groups and if so, how psychosocial and socio-economic factors are associated with these differences.


METHODS
These issues were studied based on the perinatal data of 556 948 pregnant women, who attended an obstetric clinic in Baden-Wuerttemberg in the years 1998-2003. The statistical analysis focused on testing bivariate group differences. Relative risks and odds ratios (with 95% CI) were used to describe the risk of the exposed.


RESULTS
As benefit of prenatal care was proved, deficits in prenatal care - restricted to special social groups - reinforce health inequalities. Differentiated by psychosocial factors and characteristics of horizontal inequality (marital status, nationality), differences in utilisation of prenatal care between the groups were significant. The pregnancy risk "special social burden" increased the relative risk for insufficient use to 11.69 (95% CI 8.77-15.58), the status of being an unmarried foreigner to RR 5.12 (95% CI 3.11-8.46). A similar pattern emerged, when occupational categories were discerned, affecting adversely categories with less favourable education. The low utilisation rate was always about twice as high for the group of unskilled workers than, for example, for the category "skilled workers". The association between occupational affiliation and prevention behaviour concerning low utilisation and use over standard showed no tendency towards a reduction of differences over the examined 5-year period. The percentage of foreigners was significantly higher (alpha=0.05) in the categories with insufficient use of prenatal care. Significant differences also existed regarding the choice of hospital categories for delivery. The category of women in "leading positions" used medical centres significantly (alpha=0.05) more often than pregnant women of the category "unskilled workers".


CONCLUSIONS
Even when free access to medical care concerning pregnancy and childbirth is given and overall a high educational level can be assumed in an industrialised society, health inequities are found that might affect adversely the risk of certain groups of pregnant women, belonging to the vulnerable social groups. Knowing the groups of women at risk allows a tailoring of the concept to use systematically - besides obstetric competence - the care of other medical and social experts, to introduce more pregnant women in good time and sufficiently to the antenatal care services.
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1Kompetenz-Centrum Qualitätsmanagement (KC-Q) der MDK-Gemeinschaft und des GKV-Spitzenverbandes, Lahr/Schwarzwald.
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D000328:Adult; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008875:Middle Aged; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology* / Q000517:prevention & control*; D011295:Prenatal Care / Q000706:statistics & numerical data*; D040841:Resource Allocation / Q000706:statistics & numerical data*; D012944:Social Support; D055815:Young Adult