Conditions prior to conception and during pregnancy impact the birth outcome. The California County Profile Reports include several prenatal risk factors. The risk of having suboptimal pregnancy outcomes increases in women who are experiencing their sixth or higher birth (grand multiparous).

The Healthy People 2010 Objectives establish guidelines for the remaining three factors we included county-specific data on in this section of the California County Profile Reports namely:

1.	Reducing the percent of births within 2 years of a previous birth to six percent.
2.	Reducing to ten percent the percent of women entering prenatal care after the first trimester of pregnancy.
3.	Reducing the percent of women experiencing inadequate prenatal care and/or intermediate prenatal care entry based on the Adequacy of Prenatal Care Utilization Index (APNCU) or Kotelchuck Index to ten percent or less.

The Healthy People 2010 Family Planning Objectives aim to reduce the percent of births occurring within 24 months of a previous birth to six percent. Specifically, the objective states:

"Encouraging females of all ages to space their pregnancies adequately can help lower their risk of adverse perinatal outcomes. To the extent that very closely spaced pregnancies are unplanned, unintended pregnancy may increase the risk of low birth weight. A recent study indicates that females who wait 18 to 23 months after delivery before conceiving their next child lower their risk of adverse perinatal outcomes, including low birth weight, preterm birth, and small-for- size gestational age. Health care providers can help all new mothers understand that they can become pregnant again soon after delivery and should assist them with contraceptive education and supplies."

More information on Healthy People 2010 Family Planning Objectives can be found at http://web.health.gov/healthypeople/Document/HTML/Volume1/09Family.htm.

The Healthy People 2010 Objective relating to prenatal care states:

"Prenatal care includes three major components: risk assessment, treatment for medical conditions or risk reduction, and education. Each component can contribute to reductions in perinatal illness, disability, and death by identifying and mitigating potential risks and helping women to address behavioral factors, such as smoking and alcohol use that contribute to poor outcomes. Prenatal care is more likely to be effective if women begin receiving care early in pregnancy. Since 1990, [U.S. wide] the proportion of infants whose mothers entered prenatal care in the first trimester increased 8.8 percent, from 76 percent to 83 percent. Among African Americans, this proportion grew 19 percent and among Hispanics, 22 percent. Thus, increases in early entry into prenatal care have been concentrated in those populations whose perinatal illness and disability rates and mortality rates are highest and who are most likely to have low incomes. These increases are likely due, in part, to increased access to Medicaid coverage for pregnancy-related services and improved outreach by Medicaid programs. [Grad, R., and Hill, I.T. Financing maternal and child health care in the United States. In: Kotch, J.B.; Blakely, C.; Brown, S.; et al.; eds. A Pound of Prevention: The Case for Universal Maternity Care in the U.S. Washington, DC: American Public Health Association, 1992.] In addition, the likelihood of early entry into prenatal care rises with age. The risk of poor birth outcomes is greatest among the youngest mothers (aged 15 years and under). Clearly, therefore, continued work is needed to educate women, particularly young women, about the need to begin prenatal care early in pregnancy.

Prenatal care should begin early and continue throughout pregnancy, according to accepted standards of periodicity. For example, the American College of Obstetricians and Gynecologists recommends that women receive at least 13 prenatal visits during a full-term pregnancy. [American College of Obstetricians and Gynecologists (ACOG). Manual of Standards in Obstetric-Gynecologic Practice. 2nd ed.Chicago, IL: ACOG, 1965] Therefore, assessment of the adequacy of the care pregnant women receive must include monitoring not only the month of initiation of prenatal care but also the adequacy of the care they receive throughout pregnancy. The Adequacy of Prenatal Care Utilization Index (APNCU) measures two dimensions of care: the adequacy of initiation of care and the adequacy of the use of prenatal services once care has begun (by comparing actual use to the recommended number of visits based on the month of initiation of care and the length of the pregnancy).[Kotelchuck, M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. American Journal of Public Health 84:1414-1420, 1994.] These dimensions are combined to classify each woman's prenatal care history as inadequate, intermediate, adequate, or adequate-plus. The baseline rates presented [...] include all women who received either adequate or adequate-plus care.

Overall, nearly three-quarters of women receive adequate prenatal care. However, this proportion varies across racial and ethnic groups. Certain groups, such as American Indians or Alaska Natives and Samoans, are particularly likely to receive less-than-adequate prenatal care. The likelihood of receipt of adequate prenatal care rises with maternal age, with fewer than half of pregnant women aged 15 years and under receiving adequate care. [NCHS, CDC. National Vital Statistics System, unpublished data, 1999.] Prevention of unwanted pregnancy in adolescents and education of women about the need for early, continuous prenatal care are essential."

More information on Healthy People 2010 Prenatal Care Objectives can be found at http://www.healthypeople.gov/Document/HTML/Volume2/16MICH.htm#_Toc494699663.

"For adolescents, bearing a child is associated with poor outcomes for young females and their children. Giving birth to a second child while still a teen further increases these risks. The prevention of second and subsequent births to very young females is of great interest to public health. Research has shown that such births are associated with physical and mental health problems for the mother and the child. Yet, analysis indicates that in the 2 years following the first birth, teenaged mothers have a second birth at about the same rate as other mothers. In 1997, nearly one in every five births to teenaged mothers was a birth of second order or higher."

Note that while currently the California County Profile Reports do not include tabulations on teenage mothers birth intervals, this information is included in IPODR tabulations and can be obtained upon request by contacting IPODR technical support.

The California County Profile Reports include information on timing of entry into prenatal care and on the the adequacy of prenatal care received.

Definitions

Grand multiparous mothers are women who have had six or more births (including the current birth). Note that fetal deaths are included in the count of previous births.

The birth certificate collects information on the months between the current and the previous birth. The previous birth can be a live birth or fetal death. A birth interval is considered short if the number of months between the current and last birth is 23 or less. Note that this calculation leads to a conservative estimate of the percent of births occurring within 24 months of a previous birth as births occurring in the 24th month are not included.

A woman is considered to enter prenatal care late if her first prenatal visit occurs after the first trimester of pregnancy.

The Adequacy of Prenatal Care Index (APNCU or Kotelchuck index) is based on two independent components: the initiation (timing) of prenatal care and the number of prenatal visits adjusted for the length of gestation. A woman is considered to have experienced inadequate prenatal care if the APNCU index (Kotelchuck index) indicates late or intermediate and/or too few prenatal care visits for the length of gestation. For a detailed description of and additional information on the APNCU index, click here.

Tables and Figures

Number and Percent of Births to Mothers with At Least 5 Prior Births by Race/Ethnicity, California and Contra Costa County, 2004

Race/Ethnicity	Contra Costa County		California
Race/Ethnicity	N	%	N	%
Hispanic	71	1.6	6,766	2.4
Non-Hispanic White	51	1.0	2,154	1.4
Non-Hispanic Black	38	3.3	1,338	4.7
Non-Hispanic Asian/Pacific Islander	18	1.0	832	1.3
Non-Hispanic Other Race	15	1.6	456	2.5
All	193	1.4	11,546	2.1