first antepartum visit

● (See "Prenatal care: Second and third trimesters" .)

● (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs" .)

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Prenatal care in your first trimester

Trimester means "3 months." A normal pregnancy lasts around 10 months and has 3 trimesters.

The word prenatal means before birth. The first trimester starts when your baby is conceived. It continues through week 14 of your pregnancy. Your health care provider may talk about your pregnancy in weeks, rather than in months or trimesters.

Your First Prenatal Visit

You should schedule your first prenatal visit soon after you learn that you are pregnant. Your doctor or midwife will:

• Draw your blood
• Perform a full pelvic exam
• Do a Pap smear and cultures to look for infections or problems

Your doctor or midwife will listen for your baby's heartbeat, but may not be able to hear it. Most often, the heartbeat cannot be heard or seen on ultrasound until at least 6 to 7 weeks.

During this first visit, your doctor or midwife will ask you questions about:

• Your overall health
• Any health problems you have
• Past pregnancies
• Medicines, herbs, or vitamins you take
• Whether or not you exercise
• Whether you smoke, use tobacco, drink alcohol or take drugs
• Whether you or your partner have genetic disorders or health problems that run in your family

You will have many visits to talk about a birthing plan. You can also discuss it with your doctor or midwife at your first visit.

The first visit will also be a good time to talk about:

• Eating healthy , exercising, getting adequate sleep, and making lifestyle changes while you are pregnant
• Common symptoms during pregnancy such as fatigue, heartburn, and varicose veins
• How to manage morning sickness
• What to do about vaginal bleeding during early pregnancy
• What to expect at each visit

You will also be given prenatal vitamins with iron if you are not already taking them.

Follow-up Prenatal Visits

In your first trimester, you will have a prenatal visit every month. The visits may be quick, but they are still important. It is OK to bring your partner or labor coach with you.

During your visits, your doctor or midwife will:

• Check your blood pressure.
• Check for fetal heart sounds.
• Take a urine sample to test for sugar or protein in your urine. If either of these is found, it could mean that you have gestational diabetes or high blood pressure caused by pregnancy.

At the end of each visit, your doctor or midwife will tell you what changes to expect before your next visit. Tell your doctor if you have any problems or concerns. It is OK to talk about them even if you do not feel that they are important or related to your pregnancy.

At your first visit, your doctor or midwife will draw blood for a group of tests known as the prenatal panel. These tests are done to find problems or infections early in the pregnancy.

This panel of tests includes, but is not limited to:

• A complete blood count (CBC)
• Blood typing (including Rh screen)
• Rubella viral antigen screen (this shows how immune you are to the disease Rubella)
• Hepatitis panel (this shows if you are positive for hepatitis A, B, or C)
• Syphilis test
• HIV test (this test shows if you are positive for the virus that causes AIDS)
• Cystic fibrosis screen (this test shows if you are a carrier for cystic fibrosis)
• A urine analysis and culture

Ultrasounds

An ultrasound is a simple, painless procedure. A wand that uses sound waves will be placed on your belly. The sound waves will let your doctor or midwife see the baby.

You should have an ultrasound done in the first trimester to get an idea of your due date. The first trimester ultrasound will usually be a vaginal ultrasound.

Genetic Testing

All women are offered genetic testing to screen for birth defects and genetic problems, such as Down syndrome or brain and spinal column defects.

• If your doctor thinks that you need any of these tests, talk about which ones will be best for you.
• Be sure to ask what the results could mean for you and your baby.
• A genetic counselor can help you understand your risks and test results.
• There are many options now for genetic testing. Some of these tests carry some risks to your baby, while others do not.

Women who may be at higher risk for these genetic problems include:

• Women who have had a fetus with genetic problems in earlier pregnancies
• Women, age 35 years or older
• Women with a strong family history of inherited birth defects

In one test, your provider can use an ultrasound to measure the back of the baby's neck. This is called nuchal translucency .

• A blood test is also done.
• Together, these 2 measures will tell if the baby is at risk for having Down syndrome.
• If a test called a quadruple screen is done in the second trimester, the results of both tests are more accurate than doing either test alone. This is called integrated screening. If the test is positive, an amniocentesis or cell-free DNA test may be recommended.

Another test, called chorionic villus sampling (CVS) , can detect Down syndrome and other genetic disorders as early as 10 weeks into a pregnancy.

A newer test, called cell free DNA testing, looks for small pieces of your baby's genes in a sample of blood from the mother. This test is newer, but offers a lot of promise for accuracy without risks of miscarriage. It may reduce the need for an amniocentesis, and so is safer for the baby.

There are other tests that may be done in the second trimester .

When to Call the Doctor

Contact your provider if:

• You have a significant amount of nausea and vomiting.
• You have bleeding or cramping.
• You have increased discharge or a discharge with odor.
• You have a fever, chills, or pain when passing urine.
• You have any questions or concerns about your health or your pregnancy.

Alternative Names

Pregnancy care - first trimester

Gregory KD, Ramos DE, Jauniaux ERM. Preconception and prenatal care. In:.Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 7th ed. Philadelphia, PA: Elsevier; 2021:chap 5.

Hobel CJ, Williams J. Antepartum care. In: Hacker N, Gambone JC, Hobel CJ, eds. Hacker & Moore's Essentials of Obstetrics and Gynecology . 6th ed. Philadelphia, PA: Elsevier; 2016:chap 7.

Magowan BA, Owen P, Thomson A. Antenatal and postnatal care. In: Magowan BA, Owen P, Thomson A, eds. Clinical Obstetrics and Gynaecology . 4th ed. Philadelphia, PA: Elsevier; 2019:chap 22.

Symonds I. Early pregnancy care. In: Symonds I, Arulkumaran S, eds. Essential Obstetrics and Gynaecology . 6th ed. Philadelphia, PA: Elsevier; 2020:chap 18.

Williams DE, Pridjian G. Obstetrics. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine . 9th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 20.

Review Date 4/19/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Antepartum Care

Introduction.

Antepartum care, also referred to as prenatal care, consists of the all-encompassing management of patients throughout their pregnancy course. Antepartum care has become the most frequently utilized healthcare service within the United States, averaging greater than 50 million visits annually. After the first positive pregnancy test, care is typically sought by patients and begun after confirmed sonographic intrauterine pregnancy. The average number of visits ranges between twelve to seventeen visits, depending on the complexity of the pregnancy course.

The prenatal course is typically separated into trimesters, for which each of the three trimesters serves a specific purpose for maternal/fetal monitoring, gestation-specific examinations and laboratory work, and screening for potential pregnancy abnormalities. Traditionally, prenatal visit frequencies are typically scheduled at 4-week intervals until 28 weeks of gestation, at which time visits are scheduled every 2 weeks until 36 weeks of gestation, followed by weekly visits until delivery. Visits may be adjusted to more frequent follow-ups when high-risk pregnancy complications are present, when pertinent lab values must be reviewed, or if patients require closer monitoring for risk factors. [1] [2] [3]

With the increasing focus beginning in the early 1990s on preventing maternal and fetal morbidity and mortality, great efforts have been made to improve access to quality antepartum care to low socio-economic and minority populations. Although still prevalent despite efforts, the growing disparities between minority populations (specifically among Hispanics and African Americans) are rooted in lack of access and complex obstetric and medical risk factors leading to poor obstetric outcomes. Thus, an adequate evaluation of a patient’s medical history, related risk factors, and potential obstacles to healthcare must be attained, followed by a patient-centered discussion regarding the potential prenatal plan of care. [1] [2] [3]

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First Trimester Antepartum Care (0-14 6/7 weeks)

First trimester antepartum care most commonly begins with an initial prenatal visit, after the development of symptoms, a positive pregnancy test, and confirmed intrauterine gestation via sonography. Patients with early pregnancies may present with any combination of signs and symptoms or might be completely asymptomatic. The most common presenting complaint of patients is an abrupt cessation of the menstrual cycle in previously healthy women of reproductive age with regular menstrual cycles. Although this is a common presenting complaint, menstrual cycle variation among women of varying ages or underlying gynecologic conditions also means amenorrhea cannot reliably be utilized as the only method of diagnosis of pregnancy. Patients may also present with complaints of breast pain or swelling, often less commonly reported by multiparous patients. 

Sonography, specifically transvaginal sonography, plays an essential role in identifying and establishing gestational age and confirms the location of the pregnancy. Intrauterine pregnancies are confirmed by the presence of a gestation sac within the endometrial cavity, typically identified at 4 to 5 weeks gestation, along with a visualization of a yolk sac, typically seen by 5 weeks gestation. With this confirmation, and at about 6 weeks gestation, cardiac activity may be noted.

Several major tasks must be accomplished during this initial visit, including establishing the baseline medical condition of the patient and fetus, proper gestational age and dating, and planning the intended course of obstetric care with the patient. Within the first visit, a complete history should be taken, including a detailed history of past medical problems that may be of concern during pregnancy, previous surgeries, and detailed past obstetric and gynecologic history for foreseeable complications. Current issues and complaints should also be addressed.

A complete physical examination should also be performed, including complete vital signs, maternal weight, and pelvic/cervical examination, fundal height, and fetal heart rate. Laboratory tests should also be collected and completed during this first visit. These include a complete blood count (CBC), complete metabolic panel (CMP), blood type and Rh factor testing with antibody screen, urine analysis, urine culture, pap smear screening, rubella serology, syphilis serology, gonorrhea, and chlamydia screening, Hepatitis B serology, and HIV serology. These results should be followed up promptly so as to begin necessary adjustments to prenatal care, repeat laboratory testing, or initiate treatment or a higher level of care.  During the first trimester, fetal nuchal translucency sonography and fetal aneuploidy screening may be performed between 11 and 14 weeks gestation and again during the second trimester depending on the modality of fetal aneuploidy testing utilized. [4] [5] [6] [7] [8]

Second Trimester Antepartum Care (15 0/7 - 28 6/7 weeks)

In the second trimester, antepartum care consists of updated histories with each visit, including reviewing current pregnancy-related issues and a review of newly occurring issues. This includes assessing possible symptoms such as headaches, altered vision, abdominal pain, nausea or vomiting, vaginal bleeding, leakage of fluid, or dysuria. During early second trimester gestations, patients may begin to endorse the perception of fetal movement. This is typically found at around 16 to 18 weeks gestation, or even up to 20 weeks gestation, in primigravida patients and varies in the detection based on maternal factors such as body habitus. 

Care also includes repeat blood pressure recordings, maternal weight, fundal height, and fetal heart rate. Fetal heart rates can be detected via Doppler ultrasound, in nonobese patients, at as early as 10 weeks gestation. Because the second trimester encompasses a vast majority of the rapid fetal growth period, several essential screening and laboratory tests are collected during this trimester. Earlier in the second trimester, the second portion of combined-trimester fetal aneuploidy testing or single-test quadruple maternal screening is collected between 16 to 20 weeks gestation. In addition to this, fetal sonography for the anatomic survey is performed during 18 to 20 weeks gestation.

Gestational diabetic screening is also an essential component of second-trimester testing via a 50-gram glucose tolerance test. This is typically collected between 24 to 28 weeks of gestation. Tdap vaccinations are also routinely administered during this timeframe. If patients have a known Rh-negative status, Rhogam is administered at 28 weeks. Patients during this trimester are also counseled at around 28 weeks gestation to begin self-monitoring of fetal movements equating to 10 movements within 2 hours, also known as “fetal kick counts.” [9] [10] [11]

Third Trimester Antepartum Care (29 0/7- 41 6/7 weeks)

The third trimester of antepartum care consists of the final preparations, screenings, necessary treatments, and counseling to facilitate safe and timely delivery and improved maternal and fetal outcomes. As with second-trimester visits, antepartum care in the third trimester consists of updated histories with each visit, reviewing current pregnancy-related issues and reviewing newly occurring issues. Review of new symptoms such as headaches, altered vision, abdominal pain, nausea or vomiting, vaginal bleeding, leakage of fluid, or dysuria should be discussed. If present, appropriate physical examination or laboratory testing should be completed. And, as performed in other visits, blood pressure recordings, maternal weight, fundal height, and fetal heart rate should be obtained.

Between 36 to 37 weeks gestation, third-trimester laboratory testing is typically collected in uncomplicated prenatal care. These include repeat complete blood count to address and correct anemia or thrombocytopenia prior to delivery, Hepatitis B surface antigen testing, gonorrhea and chlamydia screening, HIV screening, and Group B Streptococcal screening. During late third trimester visits, patients typically return for weekly visits to assess for signs of early labor, fetal distress, or maternal complaints.

Patients may also require a physical examination, including cervical examination, sonography to assess for estimated fetal weight and amniotic fluid index, or nonstress tests to examine fetal status. If there are abnormalities, other pregnancy-related, or maternal-related medical conditions present, patients may require induction of labor or imminent delivery depending on the circumstance and severity. [12] [13]

Issues of Concern

Several issues of concern may arise during the course of antepartum care. While serious medical conditions pose a risk and concern to prenatal management (discussed in other articles), most areas of concern in day-to-day pregnancy issues also comprise a significant amount of patient complaints. Therefore, recognition of these concerns and timely intervention is an essential contributor to adequate antepartum care. 

Nausea and Vomiting

Nausea and vomiting are among the most common complaints of pregnant patients within the first trimester of pregnancy, and is thought to be multifactorial and more directly caused by rapidly increasing level of pregnancy-related hormones such as beta HCG, estrogen, progesterone, placental growth hormone, leptin, and several others. Patients may experience varying degrees of nausea or vomiting throughout the antepartum course. Severe cases may require hospitalization and workup for more serious causes, such as hyperemesis gravidarum, identified by severe dehydration, accompanied by acid-base and electrolyte abnormalities. Patients typically state symptoms present prominently after the first missed menstrual cycle and may continue up to 16 weeks of gestation and up to 22 weeks gestation in rare cases. Symptoms are typically perceived to be more severe during early waking hours. Patients experiencing these issues may receive relief from several different interventions. First, patients may attempt to portion smaller, more frequent meals, ginger into their diets, or supplement medications. Patients may require Vitamin B6 supplementation with Doxylamine or antiemetics such as H1-receptor antagonists. [14] [15]

Musculoskeletal Back Pain

Patients during the antepartum course may also have significant complaints of back and lower lumbar pain, most commonly in the third trimester of pregnancy and caused by the increasing size of the gravid uterus and alignment distortion. This is typically worsened by walking significant distances, intense bending forward, or lifting moderately weighted objects. Severe cases of back pain may warrant orthopedic evaluation. Management of back pain includes rest, heating pads, back braces, and analgesics. [16] [17] [18]

Weight Gain

Weight gain during pregnancy should be discussed with patients and assessed based on pre-pregnancy BMI and individual risk factors, with an increased focus on obesity. Obesity’s association with fetal macrosomia, gestational diabetes, gestational hypertension, preeclampsia, rate of cesarean sections, and other pregnancy complications requires early intervention and counseling of patients beginning in early antepartum care. Pre-pregnancy BMI categories allow for stratification of the total weight gain throughout pregnancy recommendation for underweight patients (BMI <18.5) to be a 28 to 40 lb (12.7 18.1 kg) to total weight gain, normal weight (BMI: 18.5 to 24.9) to be a 25 to 35 lb (11.3 to 15.9 kg) total weight gain, overweight (BMI: 25.0 to 29.9) to be a 15 to 25 lb (6.8 to 11.3 kg) total weight gain, and obese (BMI great or equal to 30.0) to be an 11 to 20 lb (5 to 9 kg) total weight gain. The emphasis during antepartum care and weight gain is currently focused on the obese population, given the significantly increased risk for gestational diabetes, macrosomia, gestational hypertension, preeclampsia, and cesarean delivery, and other antepartum and intrapartum complications. [19] [20] [21]

Smoking, Alcohol, and Illicit Drugs Use 

Although the overall prevalence of cigarette smoking during pregnancy has decreased significantly throughout the United States, there continues to be a prevalence of twelve to thirteen percent of women who endorse cigarette use during the antepartum period. These patients typically tend to be younger in age, have completed fewer years of education, and are of lower socioeconomic status. During the antepartum course, it is essential to identify patients who endorse smoking, counsel patients extensively regarding risk factors associated with cigarette use during pregnancy, and implement a quitting plan with the identification of foreseeable roadblocks and obstacles to doing so. Cigarette smoke is fetotoxic due to the vasoactive effects leading to its substances leading to a marked reduction in oxygen levels. Effects of decreased oxygen levels may lead to cardiac anomalies, gastroschisis, hydrocephaly, microcephaly, omphalocele, cleft lip, and palate, or limb anomalies. These effects are noted to be dose-dependent. Risks associated with cigarette smoke use and exposure in the antepartum period also include spontaneous abortions, fetal growth reduction, preterm delivery, and placental abnormalities, like placental abruption or placenta previa. [22]

Like tobacco, alcohol use during pregnancy, while decreasing in prevalence, is still prevalent amongst eight to thirty percent of pregnancies in the United States. Alcohol exposure in-utero has been established as the leading cause of non-genetically linked mental retardation, along with a constellation of presenting defects that together are referred to as Fetal Alcohol Syndrome. These include notable central nervous system abnormalities (neurologic, functional, and structural dysfunction), growth restriction, notable dysmorphic facial features (short palpebral fissures, smooth philtrum, and thinned vermilion border), and other anomalies (cardiac, skeletal, renal, auditory, ophthalmologic, etc.). While the dose-effect correlation between alcohol use in pregnancy and fetal defects is unknown, several studies show an increased risk among those exposed to excessive binge-drinking behavior. [23] [24]

Illicit drug use during pregnancy is also of major concern to both maternal and fetal outcomes. With exposure rates as high as ten percent, assessing patients using recreational drugs must be completed in all pregnant patients. The use of drugs poses a unique risk when considering outcomes and fetal effects, given the multiple variables typically associated with those using drugs. These include younger patient populations, low socioeconomic status, polysubstance abuse, mental health issues, infectious diseases, and other social issues, which may complicate the picture of diagnosis and management. The greatest risk of illicit drug use in pregnancy also lies with the toxic and teratogenic effects of additives and impurities found in several street drugs. Effects of recreational drug use include, but are not limited to, fetal growth restriction, facial defects, cardiovascular, renal, and urinary abnormalities, behavioral abnormalities, and complications of fetal withdrawal (i.e., seizures, central nervous system defects). [25] [26]

Work & Employment

With more than half of pregnant women working from conception until delivery, employment during the antepartum course is another common area of concern for patients. According to the Family and Medical Leave Act, pregnant employees must be granted at least twelve weeks of unpaid leave from employment for delivery and newborn care. As per the American College of Obstetrics and Gynecology, pregnant women may continue employment until labor begins in the absence of obstetric complications.

Despite these recommendations, some work may increase the risk of complications to pregnant patients, including employment that requires strenuous heavy lifting and long work hours. These demanding conditions may place additional stress on the patient as well as the pregnancy course, leading to complications such as gestational hypertension with an increased risk of the development of preeclampsia, preterm premature rupture of membranes, preterm labor and delivery, and fetal growth restrictions. It is acceptable to counsel patients with significant obstetric histories of these complications on the added risk of strenuous workplaces on the antepartum course. [27] [28] [29]

With the emphasis on promoting healthy lifestyles during antepartum care, patients may have specific concerns regarding exercise safety during pregnancy. The American College of Obstetrics and Gynecology recommends that after thorough clinical evaluation and with no contraindications, pregnant women should be encouraged to participate in regular, moderate-intensity physical activity in regular, moderate-intensity physical activity for at least thirty minutes or greater per day. Relative contraindications are noted as follows: heavy smoking, poorly controlled disorders such as seizure disorder, hyperthyroidism, Type 1 diabetes, or hypertension, extreme weights including morbid obesity or underweight, intrauterine growth restriction, chronic bronchitis, unevaluated maternal cardiac arrhythmia, history of severely sedentary lifestyle, symptomatic or severe anemia, or heavy smoking.

Absolute contraindications as as follows: incompetent cervix or cerclage, multifetal gestation pregnancy with risk of preterm labor, persistent second or third trimester vaginal bleeding, preterm labor during in the pregnancy, placenta previa present after 26 weeks of gestation, rupture of membranes, preeclampsia or pregnancy-induced hypertension, significant heart disease, or restrictive lung disease. Specific physical activities and intensity of those activities should be reviewed. Those activities in which the risk of trauma to the abdomen or falls are increased should be discouraged. [30] [31] [32]

The American College of Obstetrics and Gynecology states that pregnant women may safely travel until 36 weeks of gestation provided there are no complications. Modern, adequately pressurized aircraft pose no harm to pregnant patients or fetuses. Patients are advised to ambulate every hour while on long flights to prevent thromboembolism and wear seat belts throughout the flight. Seat belt safety in regards to automobile travel should be discussed with all pregnant patients during antepartum care. Specifically, correct placement of seatbelts via three-point restraints where the shoulder portion of the strap should be firmly positioned between the breasts and bottom portion should safely be positioning under the abdomen and across the upper portion of the thigh. Both should be positioned across the body tightly, and airbags should always be present in vehicles and utilized in the event of a high-impact accident. [33] [34] [35]

Clinical Significance

The totality of antepartum care is an intricate balance of maternal and fetal management aimed to prevent significant maternal and fetal morbidity and mortality and provide support throughout the prenatal course. Close follow-up with timely review of new complaints or issues, significant physical exam, sonography, and laboratory findings facilitate the necessary interventions. These may include escalation of care to more frequent antepartum care visits, close follow-up by maternal-fetal medicine specialists, or potential early delivery depending on the gestational age, clinical picture, and potential improvement of outcomes.

While all of these interventions can be implemented with relative ease, major obstacles do exist to achieving this. The main concern for practitioners is patient compliance with visits, specifically in low socioeconomic or minority populations. Obstacles, such as access to prenatal facilities, transportation, or proper understanding of risk factors, all play a role in delayed intervention. Because of this, it is essential for the antepartum care team to identify these obstacles early in the prenatal course so as to preemptively find solutions to potential obstacles. [1] [2] [3]

Enhancing Healthcare Team Outcomes

During the antepartum course, the care and management of patients serve significant challenges and obstacles, given the complexity of caring for both the patient and fetus. Because of this dual perspective, a team-directed approach of care by physicians, nurses, pharmacists, and healthcare aids is essential for improving maternal and fetal outcomes. This begins with adequate antepartum or prenatal care to ensure patients feel supported and informed. This also includes early detection and acknowledgments of patient complaints, signs, and symptoms of early disease processes, vital signs, laboratory values, and antepartum and prenatal care goals.

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Pregnancy: first prenatal visit.

Your first prenatal visit will probably be the longest visit you'll have. Your doctor or midwife will take your medical history and do a complete physical exam. You may also have some tests. This will provide information that can be used to check for any problems as your pregnancy progresses.

Medical history

Your doctor or midwife will ask about your medical history. This helps your care provider plan the best possible care for your pregnancy and childbirth. Things you'll be asked about include:

• Your menstrual history. This will include your age when you had your first period, whether your cycles are regular, and the date of your last period. Information about your last period is used to estimate your due date .
• Any previous pregnancies, abortions, miscarriages, or stillbirths.
• Problems with previous pregnancies.
• Any problems with your reproductive organs .
• Health problems in your family, such as heart disease or genetic conditions .
• Your general health. This includes vaccinations, surgeries, and serious illnesses you have had. It also includes any current or past mental health issues, such as depression.
• Any medicines you take regularly. This includes prescription and over-the-counter medicines, vitamins, and supplements.
• Any habits that could affect your pregnancy, such as tobacco, alcohol, or drug use.

Physical exam

A complete physical exam may include:

• Checking your weight and blood pressure.
• A pelvic exam .
• A Pap test (if you haven't had one recently).
• A breast exam.

This may be used to confirm your pregnancy and to:

• Estimate the due date.
• Make sure the pregnancy is located in your uterus.
• Check the number of embryos in your uterus.

A urine test may be done to check for:

• Sugar in your urine. This is a sign of gestational diabetes.
• Protein in your urine. This may be a sign of kidney disease.
• Bacteria in your urine. This is a sign of a urinary tract infection (UTI). UTIs are common during pregnancy, and they may not cause symptoms. If not treated, a UTI may lead to a kidney infection.

Blood tests

You may have blood tests to check for:

• Blood type . If your blood is Rh-negative and the father's blood is Rh-positive, the fetus may have Rh-positive blood. That can lead to problems with Rh sensitization.
• Iron deficiency anemia.
• Immunity to German measles (rubella).
• HIV infection.
• Hepatitis B infection. If you are infected, your baby will be treated within 12 hours of birth. You may also be tested for hepatitis C infection.
• Gestational diabetes.

Other tests

You may have other tests to look for some conditions, such as:

• Genetic conditions that can be passed down through families. These include cystic fibrosis, sickle cell disease, and Tay-Sachs disease.
• Sexually transmitted infections (STIs) such as gonorrhea and chlamydia. STIs during pregnancy have been linked to serious problems, including miscarriage and premature birth.
• Thyroid disease. You may have thyroid tests if you have a personal or family history of thyroid problems.
• Diabetes. You may have an early blood sugar test (glucose tolerance test) if you have risk factors for having gestational diabetes.

Current as of: July 10, 2023

Author: Healthwise Staff

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• Research article
• Open access
• Published: 16 May 2018

DELAY on first antenatal care visit and its associated factors among pregnant women in public health facilities of Debre Markos town, North West Ethiopia

• Atsede Alle Ewunetie 1 ,
• Alemtsehay Mekonnen Munea 2 ,
• Belsity Temesgen Meselu 3 ,
• Muluye Molla Simeneh 1 &
• Bekele Tesfaye Meteku 4  

BMC Pregnancy and Childbirth volume  18 , Article number:  173 ( 2018 ) Cite this article

41k Accesses

48 Citations

Metrics details

Delay on timely initiation of antenatal care has a great impact on adverse pregnancy out comes. However, evidences in Ethiopia revealed that majority of pregnant mothers did not start their first visit as recommrnded by WHO. The aim of this study was to assess delay and associated factors of first antenatal care visit among pregnant mothers at public health facilities of Debremarkos town, North West Ethiopia.

An institutional based crosss-sectional study was conducted from February to March, 2014 in public health facilities of Debremarkos town North west Ethiopia. A total of 320 pregnant mothers who were sure of their last menstrual periods were interviewed with a structured questionnaire. Data entry was done using Epi data 3.1 and analysis was done using SPSS version 20. Descriptive statistics, binary and multivariable logistic regression analyses were employed to identify the magnitude and factors associated with delay on timely initiation of the first antenatal care visit.

The proportion of respondents who made their first antenatal care visit after 16 weeks of gestation was found to be 33.4%. Mothers residing in rural settings (AOR = 2.8 [95% CI:1.54–5.44]), not attained formal education(AOR = 2.2 [95% CI:1.10–4.68]),with unintended pregnancy (AOR = 3.6 [95% CI:2.00–6.80]) and who perceived that the right initiation time of the first antenatal care visit is beyond 16 weeks of gestation (AOR = 3.9 [95% CI:1.61–9.76]) were more likely delayed on their first antenatal care visit .

Residence , educational status, intention of pregnancy and perception on the right time of first antenatal care visit initiation were found to be predictors of delay on timely initiatin of first antenatal care visit. Therefore, the Zonal health department should strengthen awareness creation about timely initiation of first antenatal care visit and family planning to prevent unintended pregnancy in the community especially in the rural settings.

Peer Review reports

Many health problems of pregnant women are preventable, detectable, and treatable if they attained antenatal care (ANC) adequately [ 1 ]. The traditional approach of the ANC is a high risk approach which intended to classify pregnant women at low risk or high risk based on predetermined criteria and involved many ANC visits. This approach was hard to implement effectively since many women had at least one risk factor, and not all developed complications; at the same time, some low risk women did develop complications. It is a burden on the healthcare system. As a result, many developing countries, including Ethiopia, are adopting focused antenatal care (FANC) approach. The newly proposed, FANC recommends four ANC visits for most pregnant women. Ideally, the first visit is in the first trimester but not after 16 weeks of gestation [ 2 , 3 ].

The recommendation sets out from the fact that first trimester pregnancy stage is the fastest developmental period of the fetus, in which all organs become well developed and needs special attention [ 4 , 5 ]. However, too many women make their first antenatal visit with the pregnancy already compromised or at risk from smoking, inappropriate nutrition, ingestion of a variety of drugs, including pharmaceutical preparations, genitourinary tract infections, anemia and poor dental health [ 5 ].

Women present for antenatal care early in their pregnancy period allow enough time for essential and feasible interventions, prevention of complications and early identification of underlying conditions [ 6 ]. It also used to prevent, diagnose and treat sexually transmitted infections and work on the elimination of new Human Immune Deficiency Virus infections among new borne through providing integrated quality prevention of mother to child transmission [ 7 , 8 , 9 ].

Early attendance of ANC provides a better hemoglobin concentration through nutritional advice, prevention and early treatment of malaria and timely iron foliate supplementation [ 10 , 11 ]. Beside this, it increases the opportunity of pregnant mothers to have more prenatal care visits, sufficient tests and advice during pregnancy and a skilled birth attendant [ 12 , 13 ].

Mothers who start ANC after 22 weeks gestation, missed over four routine antenatal visits, who did not seek care or who concealed their pregnancy were manifest 17% of maternal deaths [ 14 ]. Suboptimal antenatal care was also found to be the major contributory factor for still birth in India [ 15 ]. Mothers who sought antenatal care before the end of the third month had infants who weighed heavier compared to the infants of mothers who sought care later [ 11 , 16 , 17 ].

Even though there is improvement on antenatal care coverage and the World Health Organization recommendation is initiating ANC visit in the first trimester, the time of initiation of first ANC visit is varied throughout the world. In the Ethiopian context, it is recommended that the first ANC visit should be ideally taken place before 16 weeks of pregnancy (2). In order to improve maternal health care service utilization; all governmental health institutions of Ethiopia are providing focused antenatal care service for all pregnant mothers who come to the health institutions free of charge. Early initiation of antenatal care is promoted by health extension workers and health professionals in both urban and rural Keble’s. Beside women developmental armies who are delegated in the community have their own role in community mobilization regarding to antenatal care service utilization.

According to the Ethiopia demographic, health survey, over 34% of pregnant women were attending antenatal care at least once. But, only 19% had four or more antenatal care visits during their entire pregnancy, and 11% of women made their first antenatal care visit before the fourth month of pregnancy nationwide [ 3 ]. In order to improve maternal and child health, identifying timing of first antenatal care visit among pregnant mothers and factors that affect initiation of first ANC visit is paramount. This study is designed to assess delay on first antenatal care visit among pregnant mothers and factors that affect initiation of first ANC.

Study design and data sources

An institutional based cross sectional study design was employed from February 1st through March 30, 2014 in public health facilities of Debremarkos town. Debremarkos town is the capital of East Gojjam Zone, which is located 300 km North West of Addis Ababa and 265 km away from regional capital Bahir Dar.

The study populations were pregnant women who visited public health facilities of Debremarkos town for antenatal care and randomly selected during the study period. Those pregnant mothers who were seriously ill or not aware their menstrual period were excluded from the study. The sample size was determined using single population proportion formula with the following assumptions: the proportion of delayed ANC is 74% from previous study conducted in Debre Birhan (18), maximum acceptable marginal error of 5%, an alpha level of 0.05 and a none response rate 10% were used to obtain a sample size of 326.

All public health facilities (one referral Hospital and three health centers) in Debremarkos town were included in the study. The total sample size was proportionally allocated to health facilities based on average monthly flow of pregnant mothers for ANC in each heath facility. The study subjects were recruited by using systematic random sampling technique after identification of the first study subject by simple random sampling method. Multiple enumerations due to referral were avoided using filtering questions.

The outcome variable of the study was delay on initiation of first ANC visit and the explanatory variables included Socio-demographic factors (age, religion, ethnicity, marital status, educational status, average monthly income ), Obstetric factors (parity, History of obstetric complication, history of Previous ANC visit and intention of pregnancy),Enabling factors (accessibility of information about ANC and interaction with healthprofessional ) and Reinforcing factors (perception of mothers on the advantage of the ANC, timing of ANC visit and frequency of the ANC; reasons that initiate mothers to start ANC after 16 weeks, a decision made to seek ANC, intention of partner to watrds ANC service utilization).

Delay on initiation of first antenatal care visit is initiation of first ANC visit in public health facilities which have skilled health personnel after 16 weeks of gestation.

Data were collected using structured interviewer administered questionnaire adopted from literatures and contextualized to the local situations and study objectives. The data collection tool was translated into the local language (Amharic) and pretested on 5% of the actual sample size out of the study area. Four diploma nurses and one public health professional were involved as data collector and supervisor respectively after taking 1 day training.

Ethical considerations

The study was conducted after obtaining ethical clearance from Bahir Dar University, College of medicine and Health sciences, Research Ethics Committee and letter of support from Amhara regional health bureau ethical review committee. Formal Permission paper was given to woreda health office, Debremarkos Referal Hosipital and responsible persons in each health institution accordingly. Verbal informed consent also obtained from the study participants after explaining the purpose of study. Participants were informed on their full right to skip any question or terminate their participation at any stage. Participants were also assured that there will be no harm or benefit of being participating in this study. All the information from the respondents was kept confidential.

Data processing and analysis

The data were cleaned, coded and entered in Lauritsen JM, Bruus M, Myatt M. Epi Data.A comprehensive tool for validated entry and documentation of data. 2003; 3 and transferred to IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp for analysis. Both descriptive and inferential statistics were used to summarize the data. Those variables found to be statistically significant ( p  < 0.2) in the binary logistic regression analyses were entered into the multivariable logistic regression model and statistical significance was considered at p  < 0.05.The strength of association was assessed by odds ratio (OR) with 95% confidence interval.

The response rate was 98.1%.The mean (±SD)age of respondents was 26.3(± 5.1).Among all respondents, 311 (97.2%) were Amhara in ethnic group and majority 299(93.4%) of mothers were orthodox Christian followers (Table  1 ).

Of all respondents, 107 (33.4%) made their first ANC visit after 16 weeks of gestation. The mean time was 14.5 (± 6.5) weeks with the range of 4 to 36 weeks. The median and the pick time was 12 weeks of gestation. Above half (51.2%) of mothers were start their first ANC visit in the first trimester (Fig.  1 ) .

Distribution of first ANC visits among pregnant mothers in public health facilities in Debremarkos in each trimester between February 2014 and March 2014

Among the total respondents,174 (54.4%) were multiparous. Of these, 126 (74.2%) reported that they had had experience of ANC for the preceding pregnancy. For those who had had ANC visit on preceding pregnancy, 43 (34%) visited the ANC clinic for the first time after 16 weeks of gestation in the current pregnancy. From 68 (21.2%) of mothers who had unintended pregnancy, 25 (36.8%) indicated that they had interest in interrupting their pregnancy (Table  2 ).

The available health facilities were health centers for 220 (68.8%) of respondents, Hospital for 60(10.8%) of respondents and health posts for 40(12.4%) of respondents. Of all respondents, 182 (56.9%) were advised for ANC on current pregnancy. Of these, only 38 (20.9%) had information on the time of first ANC visit. From those who had information on initiation time of ANC, 2 (5.3%) were informed to start their first visit after 16 weeks of gestation (Table  3 ).

A majority, 27 (85.3%) of respondents perceived that the ANC is important for both maternal and child health. Among delayed respondents 18 (16.8%) were initiated ANC by considering the time of their visit at the right time (Fig.  2 ).

Reasons for delay on first ANC visit among pregnant mothers who attended ANC in the public health facilities of Debre markos town between February 2014 and March 2014

Among respondents 264 (82.5%) were decided to seek ANC service jointly with their partners.From all, 287(89.4%) partners supported the need of ANC for every pregnant mothers.

The bivariate analysis showed that pregnant mothers who were residing in rural areas[Crude Odds Ratio (COR) = 3.4, 95% Confidence Interval (CI): 2.01–6.07], not attained formal education[COR = 4.5,95% CI: 2.33–8.67], farmers [COR = 7.8, 95% CI: 3.37–18.05], having less than 1000 ETB average monthly income[COR = 2.7, 95% CI: 1.45–5.37],experience one or more births [COR = 1.9, 95% CI: 1.22–3.15], not planned their pregnancy [COR = 3.9, 95% CI: 2.25–6.89], having a history of stillbirth [COR = 2.6, 95% CI: 1.01–6.90] and those who perceived that the right time of first ANCvisit is after 16 weeks of gestation [COR = 3.8, 95% CI: 1.69–9.76] were more likely delayed on initiation of the first ANC visit.After adjusting for the potential cofounders; multivariable logistic regressionanalysis indicated that residence, educational status, intention of pregnancy and perception on the right time of first ANC visit were significantly associated with delayed first ANC visit.

Mothers who were residing in rural areas, not attainding formal education, having unplanned pregnancy and perciving the right time of ANC initiation as greater than 16 weeks of gestation were more likely delayed on first ANC visit (Adjusted Odds Ratio (AOR) =2.8 [95% CI:1.54–5.44]), (AOR = 2.2 [95%CI:1.10–4.68]),(AOR = 3.6 [95% CI: 2.00–6.80]) and (AOR = 3.9[95%CI:1.61–9.76]) respectivelly (Table  4 ).

For many of the essential interventions in ANC, it is crucial to have early identification of underlying conditions. The first ANC visit should be as early as possible in pregnancy [ 10 ]. However, evidence in Ethiopia indicated that delayed ANC initiation time among pregnant mothers was high [ 18 , 19 , 20 , 21 ] .In our study,one third 107 (33.4%) of respondents were delayed to start their first ANC visit with in the first 16 weeks of pregnancy. This finding is higher as compared to a study done in Bengazie (27%, 2007) [ 22 ] . This might be due to difference in educational status of mothers between Bengazie and ours. But this finding is comparatively lower than the findings studied in Ndola (68.6%) and Mpongwe (72%) districts of Zambia [ 23 ] and South East Tanzania (81.5%) [ 24 ], EDHS,2011(89%) [ 25 ], Jimma University Specialized Hospital (60.1%) [ 26 ], Kembata tembaro Zone (68.6%) [ 27 ] and Dembech district of East Gojjam Zone,North west Ethiopia (94.2%) [ 28 ] .The possible explanation for this observed difference might be due to study population composition in which proportion of mothers residing in rural areas of current study were lower than other studies.

The finding also showed a significant association of residence and delay on timely initiation of ANC. Those mothers who were residing in rural areas were 2.8 times more likely delayed than urban mothers. Among all respondents, 56% of rural and 27% of urban residents were start ANC after 16 weeks of gestation. Ethiopian demographic and health survey, 2011, revealed that urban mothers made their first visit earlier (4.4 months) than rural mothers (5.5 months) [ 25 ]. This finding is also in agreement with the study done in Vietnam in which rural mothers were attained ANC latter and used fewer visits [ 29 ].

The possible reason might be better educational status of urban mothers than rular mothers. Because, in our study, 60% of rural mothers were not attaned formal education compared with 23% of urban mothers. The other reason might be availability of alternative health care facilities and having a better chance of health information in urban areas than rular areas. How ever, in contrary to our result,there was no significant difference in the proportionof delayed ANC attendance between urban and rular areas of Zambia [ 23 ].The reason for this difference might be the presence of more active mobile maternity service in rular than urbans areas of Zambia.

Educational status was found to have significant association with delayed initation of first ANC visit. Those mothers who had no formal education were delay two times more likely than those who had teritiary education. This is consistent with studies done in Gondar, Kembata tembaro zone,Tanzania and Ghana [ 11 , 24 , 27 , 30 ] in which women who had lower education or none booked later than those with higher education.The reason might be high chance of exposure for information in case of educated mothers.

Eventhough parity had no association with delayed initiation of ANC in our study, 40.7% of multiparous and 25.9% of nuliparous mothers were start thier first ANCvisit after 16 weeks of gestation.But, it was one of the factors for delayed initiation of ANC in different studies [ 13 , 31 , 32 ].

Intention of pregnancy was significantly associated with delay on initiation of first ANC visit. In this study, women with un planned pregnancy were 3.6 times more likely delayed to initiate first ANC visit than those mothers with planned pregnancy.This finding was inline with a study done in Kembata tembaro Zone [ 26 ]. Findings in different studies also in agreement with the association of unplanned pregnancy and delayed initiation of first ANC visit [ 18 , 32 , 33 , 34 , 35 ]. The possible reason might be mothers having intended pregnancy are much cautious and eger to know their pregnancy status and less likely delayed than those who had unintended pregnancy.

Intention of abortion in case of unintended pregnancymight also increased the chance of delayed initiation of ANC.Because, above half 14(56%) of pregnant mothers with unintended pregnancy, who looked for abortion did their first ANC visit after 16 weeks of gestation in our study.

Perception on the right time of ANC initiation was found to be significantly associated with delayed ANC visit. Those mothers who perceived that the right initiation period of first ANC visit is beyond 16 weeks of gestation, were four times delayed than their counter part.

The Possible reason might be decreased exposure for information related to ANC initiation time. Because, in this study only 38(11.8%) of mothers have got information about initiation time of ANC from other persons. Other similar studies also suggested that proper information and advice on pattern of ANC utilization is important to book early [ 33 ]; where as, not knowing the right gestational age at which to start the first antenatal care visit was the commonest reason for late ANC attendance [ 36 ]. So, appropriate perception of the initial ANC visit was a factor for an early ANC visit. This is inagreement with a study done in Gondar University Hospital [ 30 ].

Limitation of the study

The study design is not strong enough to identify determinant factors.

The magnitude of delay on initiation of first ANC visit was still high but it is lower than studies conducted in other areas of Africa and Ethiopia.The time of initiation was ranges from first timester to third trimester and the mean gestational age on initation of first ANC was arround second trimester. According to this study residence, educational status, intention of pregnancy and perception on initiation time of ANC were influencing mothers on timely initiation of first ANC visit. Awarness creation towards timely initiation of first ANC visit and family planning utilization to prevent unplanned pregnancy should be strengthen by Zonal health department in the community specially for the reproductive age group and rural residents. Ministry of education should also improve women education by strengthening adult education in the community. Further study is recommended in the rural community.

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Acknowledgements

First and for most thanks to the Almighty GOD who is our power. Our gratitude extends to East Gojjam Zone Plan and Economy department, East Gojjam zone health department, Debremarkos town adminstrative health office and health facilities.

We would like to thank Bahir Dar University and Debre Markos University for their financial and technical support.

We are also grateful to data collectors and study participants for giving us their valuable time.

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All the data supporting the study findings are within the manuscript. Additional detailed information and raw data are available from the corresponding author on reasonable request.

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Atsede Alle Ewunetie & Muluye Molla Simeneh

Department of Public Health, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia

Alemtsehay Mekonnen Munea

Department of Midwifery College of Health Sciences, Debremarkos University, Debre Markos, Ethiopia

Belsity Temesgen Meselu

Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia

Bekele Tesfaye Meteku

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Contributions

AA drafted the proposal, did the analysis, wrote the results and prepared the manuscript. AM participated on editing, analysis and write up of the result. BT, MM and BT were involved on data analysis and manuscript preparation. All authors read and approved the final manuscript.

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Correspondence to Atsede Alle Ewunetie .

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The study was conducted after obtaining ethical clearance from Bahir Dar University, College of medicine and Health sciences, Research Ethics Committee and letter of support from Amhara regional health bureau ethical review committe. Formal Permission paper was given to woreda health office, Debremarkos Referal Hosipital and responsible persons in each health institution accordingly. Verbal informed consent also obtained from the study participants after explaining the purpose of study. Participants were informed on their full right to skip any question or terminate their participation at any stage.

Participants were also assured that there will be no harm or benefit of being participating in this study. All the information from the respondents was kept confidential.

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Ewunetie, A.A., Munea, A.M., Meselu, B.T. et al. DELAY on first antenatal care visit and its associated factors among pregnant women in public health facilities of Debre Markos town, North West Ethiopia. BMC Pregnancy Childbirth 18 , 173 (2018). https://doi.org/10.1186/s12884-018-1748-7

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Received : 13 November 2017

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DOI : https://doi.org/10.1186/s12884-018-1748-7

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Content of First Prenatal Visits

The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit.

Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content.

First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening.

Conclusions for Practice

While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

Introduction

A significant and long-standing problem in healthcare is the timing, volume, and variety of care and education that could be covered during busy prenatal visits. Guidelines for the content of the first prenatal visit have been developed and endorsed by a variety of professional and public health organizations for over a century. The most recent guidelines for prenatal care, including first prenatal visits, are the 2014 American College of Obstetricians and Gynecologists (ACOG). Early and complete first prenatal visits are promoted as opportunities for screening, identifying, and addressing risk factors to improve pregnancy outcomes, provide important pregnancy education information, and establish the importance of prenatal care. However, little is known about how these guidelines are actually applied in the first prenatal visit.

There has been a rapid expansion of knowledge about the importance of the mother’s health before and during pregnancy and an increase in the number of topics to discuss within a time limited clinical encounter to adequately care for pregnant women. For example, ACOG recommends that all pregnant women, regardless of age, disease history or risk status, be routinely offered prenatal genetic screening (" ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities," 2007 ). Some research indicates that discussing the importance of breastfeeding during the first prenatal visit may increase rates and duration of breastfeeding ( Chung et al., 2008 ; " Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement," 2008 ). However, most care and education provided to women is decided upon by the individual prenatal care provider. It is unknown what care is typically provided and what topics are discussed, especially in the first prenatal visit. Before any interventions or educational tools are developed to improve how prenatal education and screening options are communicated to women, we first need to understand what care is actually provided and what health education topics are discussed.

The goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother through the determination of gestational age, identification of maternal risks, ongoing evaluation of the health status of the mother and fetus, anticipation of problems and necessary interventions, and patient education and communication ( ACOG/AAP, 2012 ). Early prenatal care also focuses on assessing maternal risk factors to support early intervention, providing of advice, offering health education, and teaching ways to address the minor problems of pregnancy ( Al-Ateeq & Al-Rusaiess, 2015 ). However, guidelines for this content vary greatly and have been criticized for failing to focus on the pregnant woman ( Hanson, VandeVusse, Roberts, & Forristal, 2009 ).

In 1925, the U.S. Department of Labor issued the Standards of Prenatal Care: An Outline for the Use of Physicians ( U.S. Department of Labor, 1925 ). Sixty years later in 1989, the U.S. Public Health Service issued a report describing the components of prenatal care, basing their recommendations on the current scientific evidence ( PHS, 1989 ). Adherence to these guidelines, as well as the 1959 ACOG guidelines, was examined in the late 1980s. Kogan et al. examined providers’ adherence to the subsequently published US P.H.S. 1989 guidelines by interviewing almost 10,000 pregnant women. Almost half of women reported that they failed to receive the recommended early prenatal examinations, laboratory tests, and health education ( Kogan, Alexander, Kotelchuck, Nagey, & Jack, 1994 ). Baldwin, et al. (1994) examined the adherence of 249 prenatal care providers (obstetricians, family physicians, certified nurse midwives) to the ACOG Guidelines of 1959 that had been in place for almost 30 years. They found that the providers followed the well established guidelines on average 80–90% of the time (range 13% to 94%).

The broad categories in these historical documents remain much the same in the most recent guidelines issued by the American College of Obstetricians and Gynecologists (2014) and separately by the American Academy of Family Practice ( Zolotor & Carlough, 2014 ). However, there has been a significant increase in the content of each category with many more patient history questions, laboratory tests, and health education topics recommended on the first prenatal visit. The result of this increased burden in terms of adherence has not yet been examined. The purpose of the current study was to examine the content of the first prenatal visit within a university hospital clinic. Clinical interactions were audio recorded and the content analyzed to identify adherence to the 2014 ACOG guidelines (" ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit," 2014 ).

Thirty first prenatal visits were audio recorded. The purpose of the recordings was described to the providers and pregnant women as assessing the type of topics covered in the prenatal visit, such as breastfeeding, vitamins, and prenatal screening. Data collection occurred in a Level 3, academic medical center obstetric clinic serving a diverse group of women receiving care under a variety of health care payment plans. All providers of care and patients were eligible for participation in this study. Patients being seen for their first prenatal visit were approached for study consent and enrolled in the examination room. Providers of care were obstetricians (MDs), certified nurse midwives (CNM), nurse practitioners (NPs), and medical students (MS). Staff involved were medical assistants (MAs). Some first prenatal visits included either an MD or NP, an MD and an NP, a CNM, and an MD and a MS. The recorder was turned on when the patient consented and prior to any interactions with a provider. The recordings were stopped when the patient exited the examination room. Audio-recordings were later transcribed verbatim and were used in the analysis. All visits took place between October 2014 and December 2014. The study was approved by the University of Utah Institutional Review Board and all patients signed written informed consent prior to any study procedures.

Audio recording transcripts were read in their entirety by the researchers. ACOG recommendations for content of first prenatal visit topics were used for comparative analysis (see Table 1 . ACOG Guidelines). The transcribed text for all first prenatal visits were uploaded into ATLAS.ti® for analysis. ( Atlas.ti, 2015 ). A qualitative content analysis was used to analyze the data. A distinguishing feature of a content analytic approach is the use of a consistent set of codes to designate data segments that contain similar material ( Elo & Kyngas, 2008 ). Consistent with our work ( Author et al., 2012 ; Author et al., 2011 ), the codes were generated from the data, and rather than using search algorithms, careful readings of the data were performed to generate the codes. Then the codes were systematically applied to the transcripts, with the ability to add codes that might have been missed with the initial development of the codebook. After coding was completed, they were summarized to identify the most frequently reported topics across the clinical visits. We addressed trustworthiness and rigor of the data to maintain data integrity during the analysis through methods of credibility and auditability ( McBrien, 2008 ). Upon completion of the coding, all data were queried within Atlas.ti® and reviewed by the research team. This allowed reviewing, verifying, and auditing the coding schema and associated data.

Percent of Visits – Adherence to ACOG Guidelines Overall (n=30 clinic visits)

After the initial analysis was complete, the content of the clinical visits was compared to the ACOG guidelines for the first prenatal visit (see Table 1 ). Any text addressing any component of each of the ACOG categories was counted as addressing the category. Incidence and density of topics were determined by the frequency of codes. However, because we relied only on verbal content, some aspects of the physical exam may have been missed if the provided did not mention it (i.e. I am taking your blood pressure now.) Descriptive statistics were used to further characterize the adherence to ACOG recommendations in these first prenatal visits by type of provider (see Table 1 ).

The analysis included thirty separate clinical visits of women seen for their first prenatal visit. An unknown number of providers of care were included and some providers could have been included more than once. Data collection was over one month and allowed a range of different providers and patients to be included in this study. Selection of participants and providers was random. Of the providers recorded there were 5 visits that included both an MD and NP, 8 visits with NP only, 14 visits with MD only, 2 with a MD and MS, and 1 with CNM. All participants and providers were English speaking. Demographic data for the patients and providers were not collected. The primary purpose of this study was the visit content discussed and adherence to ACOG guidelines for the initial reproductive visit.

Incidence of Topics Discussed

ACOG Guidelines provide a comprehensive list of topics for education and counseling to be provided at the first prenatal visit. The percent of visits in which adherence to ACOG Guidelines was identified is shown in Table 1 . Identification of adherence included mere mention of a topic and extensive discussion and/or provision of specific ACOG-recommended care or patient education. Yet, the time devoted to each topic was not accessed. In other words, these results do not represent the extent or the amount of time dedicated to the specific recommended content of prenatal care.

In this study, a clinic overview was provided to every woman. This included a number of topics, i.e. schedule of visits, availability of providers, and making appointments. In almost every visit, there was evidence of some history taken or a portion of a physical examination provided, as well as mention of routine blood testing.

Discussion of cervical cancer / pap smears and urine testing occurred in 80–83% of the visits. A confirmatory examination for pregnancy in this sample, largely represented by auscultation of fetal heart tones, occurred in three quarters of the visits. A discussion of routine laboratory testing and available genetic testing was found in 70–75% of the visits. Prenatal vitamins and iron were also routinely addressed in over 70% of visits, and flu vaccine was offered (57%).

Gathering of a family medical history, assessment of and education about alcohol, tobacco, and / or drugs were found in slightly over half the visits. Exercise counseling occurred in about half the visits. As specific complications were not known for each woman, any mention of complications in the transcripts, such as twins or vaginal birth after cesarean, was counted as fulfilling the ACOG recommendation, occurring in 26% of visits. Any discussion of the process of pregnancy was identified as fulfilling the ACOG recommendation of educating the women about the expected course of pregnancy, found in 20% of visits. Psychosocial needs assessment visit guidelines were followed in less than 10%.

None of the recordings indicated that a complete initial history, assessment for pre-term labor risk, or complete physical examination was completed (i.e. abdomen, breasts and inquiries about bladder and bowel functions, weight gain, and vital signs). ACOG guidelines indicate a complete needs assessment should be done. This complete assessment was not found on recordings of any visits although additional visits could have addressed these patient needs. Screening for domestic violence or depression was not found in any recording, with depression rarely addressed in the first prenatal visit. Education on most ACOG recommended first prenatal visit topics (labor & delivery, working, air travel, dental care, over the counter medication use, pets and seat belt use) was rarely or never found on recordings. Psychosocial issues were rarely addressed on the audio tapes. Prenatal classes, while often not attended until late in pregnancy, were never mentioned nor was there an investigation of any barriers to receiving care in any visit. Specific content of the routine laboratory and diagnostic testing was not discussed in the recordings or known to researchers. As no histories of the women were available to researchers, women who were at risk for gestational diabetes (GDM) or pre-term labor were not identified to know who merited education or early screening. GDM screening was not discussed with any woman.

First prenatal visits are often scheduled throughout an MD / CNM / NP’s clinical day, interspersed with other types of pregnancy and gynecologic patient visits. Providers work under time constraints with multiple patients scheduled in quick succession. This can result in abbreviated visits, omission of ideal health education, reliance on other staff to collect information and provide patient education, and addressing only the most obvious problems. Given clinical time constraints, many providers rely on provision of printed materials to patients to compensate for the lack of time available for direct face-to-face patient education. Whether printed materials are an effective or optimal approach to delivering patient education or not, is questionable ( Nolan, 2009 ). Further, some topics may be discussed in future visits to account for the limited time in only one clinical visit.

The study results suggest that several ACOG guidelines are being addressed, particularly those related to medical care and intervention – vitamins and iron, blood and urine laboratory studies, flu vaccine, and screening for cervical cancer. However, the extent of discussion or amount of time dedicated to meeting ACOG recommendations, are unknown. For example, the mention of “genetic screening” in the transcribed audio recording was coded and reported as “addressed” during the prenatal visit. However, genetic screening is a complex topic and it is unknown if it was fully discussed during the visit or was it merely mentioned that information about genetic screening as provided in the printed material distributed to the patient.

It is unknown what information was already contained in the EMR, although the EMR format is known to allow for the documentation of all the ACOG recommended information. Initial historical information, family history, genetic history, and risk of pre-term labor could have already been in the EMR or data could have been entered outside the examination room. Video recordings, rather than audio recordings, could have revealed that a physical examination occurred, as there was no specific mention of a completed physical examination in the audio recording. Finally, as discussed above. first visit prenatal education recommended by ACOG may have occurred in a different formast, for example, printed materials distributed to patients. Further, some of the patients may have undergone a “confirmatory pregnancy” appointment and topics not discussed in this recorded visit could have occurred as well as in future visits. Audio recordings revealed that packets of prenatal information were often given, however the exact content is unknown.

The prenatal visit discussions in this study were focused on information gathering with mostly closed ended questions used by providers, usually resulting in patient responses of “yes or no”. This style of questioning discourages full and meaningful responses that could have provided additional information of importance to patient care. The providers in this study addressed concerns that were expressed by the women, but rarely asked women about their concerns or fears. Discussing a woman’s concerns and fears can reveal risk factors that should be addressed or a further discussion can allay fears once identified. Many providers referenced the authoritative recommendations of health care profession groups, such as ACOG and others, without further discussion. An explanation of the risks, benefits, and/or alternatives to that recommended care was rarely offered.

A larger question that should be considered is how the content of the ACOG recommendations can be addressed while including patient driven needs and preferences in these guidelines. Many of the components of the ACOG Guidelines are based on tradition with a limited number of topics supported by careful research ( Zolotor & Carlough, 2014 ; Kirkham, Harris, & Grzybowski, 2005 ). Further research is needed to explore the value of all of the components, with the goal of including only those that have proven value. Women’s needs and preferences have not been routinely included in published guidelines ( Hanson et al., 2009 ), implying that these are of lesser importance or additional avenues outside the clinic visit need to be explored to address patient.

Lastly, forming relationships with patients requires time, the use of open-ended questions, and repeated visits. It is unreasonable to assume that such a close relationship will occur at the first prenatal visit. This study demonstrated the issues of provider time constraints based on their recorded comments are related to lack of adherence to ACOG’s education recommendations,, and lack of screening for unstated problems.

Limitations

This study took place in one outpatient clinic in a Level 3, academic medical center obstetrics clinic. Other practice settings, such as a private office, birth center or home birth setting, may structure first prenatal visits very differently. The majority providers of care were MDs and no comparisons can be made of their care to the care of the few CNMs or NPs in this study. Further, the content of the visit was descriptively compared between different providers. It would be interesting to assess how different professionals prioritize different topics during time limited clinical encounters as well as how patients’ driven questions influence the topics covered. Researchers lacked access to knowledge about existing information in the EMR or when the EMR was used. Audio recordings missed the visual information and nuances of a video recording, which would have provided additional information about first prenatal visit content. Lastly, content analysis did not address the extent to which ACOG guidelines were followed, nor the amount of time dedicated to provision of care or patient education. Future studies should include these aspects of ACOG guideline adherence to better understand the effectiveness of prenatal care and include additional prenatal visits.

This study demonstrated that standard ACOG guidelines for first prenatal visit content were inconsistently followed at one site by one group of providers based on audio recordings. Providers more closely adhered to ACOG guidelines that addressed vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Content addressing many components of the examination, education about pregnancy, and screening for an identification of psychosocial risk was identified less often. Providers routinely used an interview style that did not elicit extensive information. While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study.

Acknowledgments

We would like to thank the University of Utah College of Nursing Research Committee for helping fund this study.

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Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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Rosatom Starts Production of Rare-Earth Magnets for Wind Power Generation

TVEL Fuel Company of Rosatom has started gradual localization of rare-earth magnets manufacturing for wind power plants generators. The first sets of magnets have been manufactured and shipped to the customer.

In total, the contract between Elemash Magnit LLC (an enterprise of TVEL Fuel Company of Rosatom in Elektrostal, Moscow region) and Red Wind B.V. (a joint venture of NovaWind JSC and the Dutch company Lagerwey) foresees manufacturing and supply over 200 sets of magnets. One set is designed to produce one power generator.

“The project includes gradual localization of magnets manufacturing in Russia, decreasing dependence on imports. We consider production of magnets as a promising sector for TVEL’s metallurgical business development. In this regard, our company does have the relevant research and technological expertise for creation of Russia’s first large-scale full cycle production of permanent rare-earth magnets,” commented Natalia Nikipelova, President of TVEL JSC.

“NovaWind, as the nuclear industry integrator for wind power projects, not only made-up an efficient supply chain, but also contributed to the development of inter-divisional cooperation and new expertise of Rosatom enterprises. TVEL has mastered a unique technology for the production of magnets for wind turbine generators. These technologies will be undoubtedly in demand in other areas as well,” noted Alexander Korchagin, Director General of NovaWind JSC.

For reference:

TVEL Fuel Company of Rosatom incorporates enterprises for the fabrication of nuclear fuel, conversion and enrichment of uranium, production of gas centrifuges, as well as research and design organizations. It is the only supplier of nuclear fuel for Russian nuclear power plants. TVEL Fuel Company of Rosatom provides nuclear fuel for 73 power reactors in 13 countries worldwide, research reactors in eight countries, as well as transport reactors of the Russian nuclear fleet. Every sixth power reactor in the world operates on fuel manufactured by TVEL. www.tvel.ru

NovaWind JSC is a division of Rosatom; its primary objective is to consolidate the State Corporation's efforts in advanced segments and technological platforms of the electric power sector. The company was founded in 2017. NovaWind consolidates all of the Rosatom’s wind energy assets – from design and construction to power engineering and operation of wind farms.

Overall, by 2023, enterprises operating under the management of NovaWind JSC, will install 1 GW of wind farms. http://novawind.ru

Elemash Magnit LLC is a subsidiary of Kovrov Mechanical Plant (an enterprise of the TVEL Fuel Company of Rosatom) and its main supplier of magnets for production of gas centrifuges. The company also produces magnets for other industries, in particular, for the automotive

industry. The production facilities of Elemash Magnit LLC are located in the city of Elektrostal, Moscow Region, at the site of Elemash Machine-Building Plant (a nuclear fuel fabrication facility of TVEL Fuel Company).

Rosatom is a global actor on the world’s nuclear technology market. Its leading edge stems from a number of competitive strengths, one of which is assets and competences at hand in all nuclear segments. Rosatom incorporates companies from all stages of the technological chain, such as uranium mining and enrichment, nuclear fuel fabrication, equipment manufacture and engineering, operation of nuclear power plants, and management of spent nuclear fuel and nuclear waste. Nowadays, Rosatom brings together about 350 enterprises and organizations with the workforce above 250 K. https://rosatom.ru/en/

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Putin taunts the West with 'first ever' visit to remote ice-covered 'frontier region' just 55 miles from the US - as Zelensky tries to drum up war support in Lithuania

• Chukotka is Russia's easternmost region, sharing a maritime border with Alaska

President Vladimir Putin  has arrived for his first-ever presidential visit to Chukotka in Russia 's Far East - just 55 miles from the US state of Alaska . 

Putin arrived in Anadyr, the local capital of the Chukotka region this morning after flying from Moscow some nine time zones away. 

Chukotka is the easternmost region of Russia, with a maritime border on the Bering Strait with Alaska.

The Russian president was met in Anadyr by a motorcade and was whisked away in a limousine amid frigid temperatures of -28C. 

It's the closest he has come to US soil since he met with President  Barack Obama in New York City in 2015.

Chukotka is so close to Alaska that Roman Abramovich - the ex-Chelsea FC owner - was reported to fly to Anchorage in Alaska for lunch when he was the governor of the region from 2001 - 2008.

Putin's visit comes at a time when US-Russian relations are at their lowest ebb in decades amid the war in Ukraine and a growing East-West divide. 

Meanwhile, Ukrainian President Volodymyr Zelensky today landed in Lithuania as part of an unannounced trip to the Baltic states to drum up more support for the conflict. 

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The three Baltic states - all former Soviet republics which are now EU and NATO members - are among Ukraine's staunchest allies.

'Estonia, Latvia, and Lithuania are our reliable friends and principled partners. Today, I arrived in Vilnius before going to Tallinn and Riga,' Zelensky said on social media platform X, formerly Twitter.

'Security, EU and NATO integration, cooperation on electronic warfare and drones, and further coordination of European support are all on the agenda,' he said.

The Baltic tour marks Zelensky's first official trip abroad this year.

In Lithuania, a key donor to Ukraine, Zelensky said he will hold talks with the president, prime minister and the speaker of parliament, and meet with the Ukrainian community.

The visit comes as other Kyiv allies waver on fresh aid, nearly two years into Russia's invasion.

Ukraine has come under intense Russian shelling in recent weeks, retaliating with strikes on Russia's border city of Belgorod.

Zelensky has urged allies to keep military support flowing and held in-person talks with officials from the United States, Germany and Norway last month.

But an EU aid package worth 50 billion euros ($55 billion) has been stuck in Brussels following a veto by Hungary, while the US Congress remains divided on sending additional aid to Ukraine.

Following his trip to Chukotka, Putin is expected to visit several regions in the Russian Far East to boost his re-election campaign amid the war with Ukraine, which has seen more than 300,000 Russians killed or maimed.

He is due to stand in March, seeking another six years in the Kremlin.

The only Kremlin leader ever to travel to Chukotka previously was Dmitry Medvedev in 2008.

Putin's trip sees him escape a wave of ugly protests in western Russia over hundreds of thousands of people scraping by in freezing conditions due to breakdowns in communal heating supplies.

In Elektrostal, Moscow region, desperate residents say they have had no communal heating - which Russians routinely expect the state to supply usually through piped hot water - for the entire winter so far.

'We have been without heating since [9 October],' one resident said in a video circulating on Telegram.

'It is impossible to be in our homes… We are freezing! We are freezing! We are freezing!' they said.