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Prenatal Care in the First Trimester

How many women start prenatal care their first trimester of pregnancy?

About five of six mothers (84%) began prenatal care in their first three months of pregnancy in 2003, with no apparent increase in 2004. Rates varied among the states, and only three states met the national goal of 90 percent in 2004.

Slide For Prenatal Care in the First Trimester
Slide For Prenatal Care in the First Trimester
Slide For Prenatal Care in the First Trimester

Why is this important?

Women's health experts recommend that women initiate prenatal care in the first three months of their pregnancy. Early initiation of prenatal care can be beneficial (Alexander and Korenbrot 1995; McCormick and Siegel 2001) through:

  • early identification of risk factors and provision of preventive advice to encourage healthy lifestyle;
  • treatment of conditions such as diabetes and high blood pressure; and
  • referrals to services such as nutrition and smoking cessation programs.
Prenatal care helps improve maternal health and survival and may contribute to improved infant survival by linking women with high-risk pregnancies to better obstetrical and neonatal care (Bronstein et al. 1995; McCormick and Siegel 2001; Vintzileos et al. 2002). Mothers who obtain adequate prenatal care appear to establish positive care-seeking behavior that makes them more likely to obtain preventive care for their infants (Kogan et al. 1998).


Among mothers of babies born live in the United States in 2003, about 600,000 or one of every six (16%) did not start prenatal care in the first trimester of her pregnancy. The rate in 2003 represented a 16 percentage point improvement compared with 1970, when one of three mothers (32%) did not begin prenatal care early (Martin et al. 2005).

The overall rate did not increase from 2003 to 2004 in areas (41 states, the District of Columbia, and New York City) for which there were comparable data in both years. In these areas, 2004 rates ranged from 69 percent in New Mexico to 90 percent in Rhode Island. Rates decreased in 26 of these areas and increased in 16 others (Martin et al. 2006).

Only three states in 2004 and four states in 2003 achieved the national Healthy People 2010 goal of 90 percent or higher.


Access to prenatal care improved during the past decade as a result of expansions in Medicaid coverage for low-income pregnant women (Howell 2001). Yet, the women most likely to benefit from early prenatal care because of their higher risk of poor birth outcomes—teens, blacks, and those who are unmarried and have less education—remain less likely to receive it (Alexander et al. 2002).

One-half of women who started prenatal care late said they would like to have started care earlier, but many didn't know that they were pregnant (CDC 2000). Commonly cited barriers to prenatal care include not being able to afford it, lack of transportation and child care, not being able to get an appointment, and negative attitudes toward health professionals or health care in general (Alexander and Korenbrot 1995; CDC 2000; Sanders-Phillips and Davis 1998).

Improvement Ideas and Resources

The Center for Health Care Strategies offers a toolkit to help Medicaid and State Children's Health Insurance Programs improve prenatal care and birth outcomes. It includes strategies for identification, stratification, outreach, and intervention as well as communications tactics for creating change.

Many state Medicaid programs are providing enhanced prenatal care services such as case management, nutritional and psychosocial counseling, and home visiting. Comprehensive programs that target such services to high-risk women can help improve birth outcomes such as low-birthweight (Baldwin et al. 1998; Ricketts et al. 2005) and reduce the use of neonatal intensive care (Stankaitis et al. 2005).


The rate of first trimester prenatal care was computed using the 1989 Revision to the U.S. Standard Birth Certificate (except as noted below) for all registered births in the 50 states and District of Columbia (more than 99 percent of births in the U.S. are registered). The denominator included all the birth certificates that listed the month that prenatal care began (about 98 percent of all birth certificates) (Martin et al. 2005).

The 2003 Revision of the U.S. Standard Certificate of Live Birth was adopted by Pennsylvania and Washington in 2003 and by Florida, Idaho, Kentucky, New Hampshire, New York (except New York City), South Carolina, and Tennessee in 2004. Because of changes in the certificate, rates of prenatal care initiation are not comparable between states using the 1989 and 2003 revision. Rates for 2004 could not be computed for Florida and New Hampshire, which implemented the revised certificate after January 1 of the year (Martin et al. 2006).


Despite increased access to prenatal care, rates of preterm birth and low-birthweight births have been worsening, although this trend is partly explained by an increase in multiple births (Martin et al. 2005). Further increases in prenatal care may have limited impact on birth outcomes unless more effective medical and psychosocial interventions are provided to those at need, both before and during pregnancy (Alexander and Kotelchuck 2001; Shiono and Behrman 1995).


Researchers at the National Center for Health Statistics analyzed birth certificate data in the National Vital Statistics System (Martin et al. 2005, 2006).


* Indicates source of data used in chart(s).

Alexander, G. R., M. Kogan, D., and S. Nabukera. 2002. Racial Differences in Prenatal Care Use in the United States: Are Disparities Decreasing? American Journal of Public Health 92 (12): 1970–5.

Alexander, G. R., and C. C. Korenbrot. 1995. The Role of Prenatal Care in Preventing Low Birth Weight. Future Child 5 (1): 103–20.

Alexander, G. R., and M. Kotelchuck. 2001. Assessing the Role and Effectiveness of Prenatal Care: History, Challenges, and Directions for Future Research. Public Health Reports 116 (4): 306–16.

Baldwin, L. M., E. H. Larson, F. A. Connell et al. 1998. The Effect of Expanding Medicaid Prenatal Services on Birth Outcomes. American Journal of Public Health 88 (11): 1623–9.

Bronstein, J. M., E. Capilouto, W. A. Carlo et al. 1995. Access to Neonatal Intensive Care for Low-Birthweight Infants: The Role of Maternal Characteristics. American Journal of Public Health 85 (3): 357–61.

CDC (Centers for Disease Control and Prevention). 2000. Entry into Prenatal Care—United States, 1989–1997. Morbidity and Mortality Weekly Report 49(18): 393–7.

Howell, E. M. 2001. The Impact of the Medicaid Expansions for Pregnant Women: A Synthesis of the Evidence. Medical Care Research and Review 58 (1): 3–30.

Kogan, M. D., G. R. Alexander, B. W. Jack et al. 1998. The Association Between Adequacy of Prenatal Care Utilization and Subsequent Pediatric Care Utilization in the United States. Pediatrics 102 (1 Pt 1): 25–30.

* Martin, J. A., B. E. Hamilton, P. D. Sutton et al. 2005. Births: Final Data for 2003. National Vital Statistics Reports 54 (2).

* Martin, J. A., B. E. Hamilton, P. D. Sutton et al. 2006. Births: Final Data for 2004. National Vital Statistics Reports 55 (1).

McCormick, M. C., and J. E. Siegel. 2001. Recent Evidence on the Effectiveness of Prenatal Care. Ambulatory Pediatrics 1 (6): 321–5.

Ricketts, S. A., E. K. Murray, and R. Schwalberg. 2005. Reducing Low Birthweight by Resolving Risks: Results from Colorado's Prenatal Plus Program. American Journal of Public Health 95 (11): 1952–7.

Sanders-Phillips, K., and S. Davis. 1998. Improving Prenatal Care Services for Low-Income African American Women and Infants. Journal of Health Care for the Poor and Underserved 9 (1): 14–29.

Shiono, P. H., and R. E. Behrman. 1995. Low Birth Weight: Analysis and Recommendations. The Future of Children 5 (1): 4–18.

Stankaitis, J. A., H. R. Brill, and D. M. Walker. 2005. Reduction in Neonatal Intensive Care Unit Admission Rates in a Medicaid Managed Care Program. American Journal of Managed Care 11 (3): 166–72.

Vintzileos, A. M., C. V. Ananth, J. C. Smulian et al. 2002. The Impact of Prenatal Care on Neonatal Deaths in the Presence and Absence of Antenatal High-Risk Conditions. American Journal of Obstetrics and Gynecology 186 (5): 1011–6.