Over the past 30 years, the United States has experienced a major decrease in infant mortality, especially mortality in the neonatal period. Despite this dramatic change, the United States remains at a very disadvantaged position among industrialized countries when they are ranked by infant mortality rate. This situation reflects the conjunction of two trends. The first is the increasing technological sophistication and success of perinatal services in sustaining the survival of ever tinier infants (Richardson et al., 1998). The second trend, which offsets the first, is the persistence of high rates of low birth weight and prematurity, and even increases in rates of such births among African Americans. Another contributing factor is the persistence of a steady rate of major congenital malformations. Despite the fact that most industrialized countries experience similar malformation rates, they have been able to reduce the percentage of preterm deliveries while also incorporating technological interventions into the care of those who are born prematurely (Guyer et al., 1996).

The strategy that has been advocated to reduce the rate of preterm and low birth weight births in the U.S. reflects a short-term, clinical approach that consists of increasing access to early and regular prenatal care (IOM, 1985, 1988). Advocates for changing financial and other barriers to prenatal care base their arguments on conclusions of cost-effectiveness of prenatal care in changing birth weight or duration of gestation (Gorsky and Colby, 1989; IOM, 1985; Korenbrot, 1984).

Introduction

The conference that formed the basis for this book was motivated in large part by recurrent questions in the literature regarding the value of prenatal care. Research has examined whether efforts to improve the access of pregnant women to timely prenatal care have been a successful means of improving birth outcomes. Although some reports have enthusiastically supported the accomplishments of prenatal care (IOM, 1985); others have stressed the equivocal nature of the empirical evidence, and their conclusions have been more guarded (Alexander and Korenbrot, 1995; Kogan et al., 1998; Fiscella, 1995).

Some of the more pointed commentaries on the value of prenatal care have occurred in the context of articles addressing cost-effectiveness. Several influential reports and studies have concluded that prenatal care is a cost-effective intervention based on its impact on specific adverse outcomes of pregnancy, namely low birth weight and prematurity. These studies have calculated the monetary savings resulting from the use of prenatal care (IOM, 1985; Gorsky and Colby, 1989; Korenbrot, 1984; Schramm, 1992), figures readily cited in policy debates. However, other authors have sharply contested these conclusions regarding cost-effectiveness (Huntington and Connell, 1994).

Here, we examine some of the issues relevant to assessing the value of prenatal care that have been highlighted in this book. The premise of this book, as described in the Introduction, is that the arguments for and the critiques of the effectiveness and cost-effectiveness of prenatal care are based on a very narrow conceptualization of both prenatal care and the relevant outcomes.