Original Research| Volume 3, ISSUE 5, 100442, September 2021

Geographic barriers to prenatal care access and their consequences


      Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes.


      This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services.


      This was a retrospective cohort study of pregnant women delivering at ≥24 weeks’ gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks’ gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features.


      Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95–3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic.


      Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.

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        • Ballantyne JW.
        Visits to the wards of the promaternity hospital: a vision of the twentieth century.
        Am J Obstet Dis Women Child. 1901; 43: 593
        • Williams JW.
        The limitations and possibilities of prenatal care.
        JAMA. 1915; LXIV: 95-101
        • Eastman NJ.
        Prematurity from the viewpoint of the obstetrician.
        Am Pract Dig Treat. 1947; 1: 343-352
        • Peahl AF
        • Howell JD.
        The evolution of prenatal care delivery guidelines in the United States.
        Am J Obstet Gynecol. 2021; 224: 339-347
        • Ghulmiyyah L
        • Sibai B.
        Maternal mortality from preeclampsia/eclampsia.
        Semin Perinatol. 2012; 36: 56-59
        • Liu CM
        • Chang SD
        • Cheng PJ.
        Relationship between prenatal care and maternal complications in women with preeclampsia: implications for continuity and discontinuity of prenatal care.
        Taiwan J Obstet Gynecol. 2012; 51: 576-582
        • Rosen MG
        • Merkatz IR
        • Hill JG.
        Caring for our future: a report by the expert panel on the content of prenatal care.
        Obstet Gynecol. 1991; 77: 782-787
        • MacDorman MF
        • Declercq E
        • Cabral H
        • Morton C.
        Recent increases in the U.S. Maternal mortality rate: disentangling trends from measurement issues.
        Obstet Gynecol. 2016; 128: 447-455
        • Baeva S
        • Saxton DL
        • Ruggiero K
        Identifying maternal deaths in Texas using an enhanced method, 2012.
        Obstet Gynecol. 2018; 131: 762-769
        • Maternal Mortality and Morbidity Task Force
        Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report.
        2018 (Available at:) (Accessed May 1, 2021)
        • Petersen EE
        • Davis NL
        • Goodman D
        • et al.
        Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013–2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429
        • Main EK.
        Reducing maternal mortality and severe maternal morbidity through state-based quality improvement initiatives.
        Clin Obstet Gynecol. 2018; 61: 319-331
        • D'Alton ME
        • Bonanno CA
        • Berkowitz RL
        • et al.
        Putting the “M” back in maternal-fetal medicine.
        Am J Obstet Gynecol. 2013; 208: 442-448
        • Creanga AA
        • Bateman BT
        • Kuklina EV
        • Callaghan WM.
        Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010.
        Am J Obstet Gynecol. 2014; 210: 435.e1-435.e8
        • Creanga AA
        • Bateman BT
        • Mhyre JM
        • Kuklina E
        • Shilkrut A
        • Callaghan WM.
        Performance of racial and ethnic minority-serving hospitals on delivery-related indicators.
        Am J Obstet Gynecol. 2014; 211 (647.e1-647.16)
        • Fang J
        • Madhavan S
        • Alderman MH.
        Maternal mortality in New York City: excess mortality of black women.
        J Urban Health. 2000; 77: 735-744
        • Goffman D
        • Madden RC
        • Harrison EA
        • Merkatz IR
        • Chazotte C.
        Predictors of maternal mortality and near-miss maternal morbidity.
        J Perinatol. 2007; 27: 597-601
        • Wang E
        • Glazer KB
        • Howell EA
        • Janevic TM.
        Social determinants of pregnancy-related mortality and morbidity in the United States: a systematic review.
        Obstet Gynecol. 2020; 135: 896-915
        • Leveno KJ
        • McIntire DD
        • Bloom SL
        • Sibley MR
        • Anderson RJ.
        Decreased preterm births in an inner-city public hospital.
        Obstet Gynecol. 2009; 113: 578-584
        • Holcomb D
        • Faucher MA
        • Bouzid J
        • Quint-Bouzid M
        • Nelson DB
        • Duryea E.
        Patient perspectives on audio-only virtual prenatal visits amidst the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.
        Obstet Gynecol. 2020; 136: 317-322
        • Martin JA
        • Osterman MJ
        • Kirmeyer SE
        • Gregory EC.
        Measuring gestational age in vital statistics data: transitioning to the obstetric estimate.
        Natl Vital Stat Rep. 2015; 64: 1-20
        • Fiscella K.
        Does prenatal care improve birth outcomes? A critical review.
        Obstet Gynecol. 1995; 85: 468-479
        • Alexander GR
        • Kotelchuck M.
        Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research.
        Public Health Rep. 2001; 116: 306-316
        • Creanga AA
        • Berg CJ
        • Syverson C
        • Seed K
        • Bruce FC
        • Callaghan WM.
        Pregnancy-related mortality in the United States, 2006-2010.
        Obstet Gynecol. 2015; 125: 5-12
        • Moaddab A
        • Dildy GA
        • Brown HL
        Health care disparity and pregnancy-related mortality in the United States, 2005-2014.
        Obstet Gynecol. 2018; 131: 707-712
      1. Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy.
        Obstet Gynecol. 2017; 130: e81-e94
        • Jackson A
        • Shannon L.
        Barriers to receiving substance abuse treatment among rural pregnant women in Kentucky.
        Matern Child Health J. 2012; 16: 1762-1770
        • Sutter MB
        • Gopman S
        • Leeman L.
        Patient-centered care to address barriers for pregnant women with opioid dependence.
        Obstet Gynecol Clin North Am. 2017; 44: 95-107
        • Clapp MA
        • James KE
        • Kaimal AJ
        • Sommers BD
        • Daw JR.
        Association of Medicaid expansion with coverage and access to care for pregnant women.
        Obstet Gynecol. 2019; 134: 1066-1074
      2. Implementing telehealth in practice: ACOG Committee Opinion Summary, Number 798.
        Obstet Gynecol. 2020; 135: 493-494
        • DeNicola N
        • Grossman D
        • Marko K
        • et al.
        Telehealth interventions to improve obstetric and gynecologic health outcomes: a systematic review.
        Obstet Gynecol. 2020; 135: 371-382
        • Peahl AF
        • Novara A
        • Heisler M
        • Dalton VK
        • Moniz MH
        • Smith RD.
        Patient preferences for prenatal and postpartum care delivery: a survey of postpartum women.
        Obstet Gynecol. 2020; 135: 1038-1046
        • Peahl AF
        • Gourevitch RA
        • Luo EM
        Right-sizing prenatal care to meet patients’ needs and improve maternity care value.
        Obstet Gynecol. 2020; 135: 1027-1037
        • Peahl AF
        • Smith RD
        • Moniz MH.
        Prenatal care redesign: creating flexible maternity care models through virtual care.
        Am J Obstet Gynecol. 2020; 223 (389.e1-389.10)
        • Turrentine M
        • Ramirez M
        • Monga M
        Rapid deployment of a drive-through prenatal care model in response to the coronavirus disease 2019 (COVID-19) pandemic.
        Obstet Gynecol. 2020; 136: 29-32
        • Kalmuss D
        • Fennelly K.
        Barriers to prenatal care among low-income women in New York City.
        Fam Plann Perspect. 1990; 22: 215-218
        • Mazul MC
        • Salm Ward TC
        • Ngui EM
        Anatomy of good prenatal care: perspectives of low income African-American women on barriers and facilitators to prenatal care.
        J Racial Ethn Health Disparities. 2017; 4: 79-86