Adequacy of Prenatal Care: A Mapping Study with an Emphasis on Postpartum Hemorrhage

Objective: This study aims to assess whether the adequacy of prenatal care influences the risk of postpartum hemorrhage (PPH), and to identify modifiable risk factors within our patient population that could reduce PPH incidence. Methods: A retrospective cohort study was performed with permission from the Institutional Review Board (Ascension Health IRB #RIN20230014)​​. Study participants were patients from the Ascension St. Vincent Women’s Health Clinic in Indianapolis, a community hospital residency based program. Eligibility criteria was only on the basis of the patient delivering at the Ascension St. Vincent Women’s Hospital. A total of 5,502 patients were eligible; of these, 663 women were included in the final analysis. All data were de-identified. Patient information was collected using the REDCAP platform, with supplemental qualitative data extracted from Sovera, Athena, Centricity, and Allscripts-Sunrise. Data were collected from January 2017 to February 2023. Variables included patient age at delivery, gestational age at delivery (in weeks), mode of delivery (vaginal or cesarean section), gravida and parity, and the presence or absence of PPH during the index pregnancy (defined as a blood loss > 1000mL). The adequacy of prenatal care was assessed using the Adequacy of Prenatal Care Utilization (APNCU) developed by Dr. Milton Kotelchuck. This index considers the gestational week care began, total number of prenatal visits, and birth weight at delivery Statistical analysis included descriptive statistics and bivariate comparisons to assess the relationship between patient characteristics and occurrence of PPH. Categorical variables were analyzed using Pearson’s chi-square test. Continuous variables, such as maternal age and gestational age, were compared using the Mann-Whitney U test due to non-normal distribution. Adequacy of prenatal care was categorized and compared between groups (inadequate vs. intermediate/adequate/adequate plus) using Pearson’s chi-square test to evaluate its association with PPH. Statistical significance was defined by p<0.05. Results: Of the 663 patients initially included, 12 were excluded due to missing documentation on PPH status, resulting in a final sample of 651 patients. Among them, 35 (5.4%) experienced PPH. Median patient age at delivery for the PPH group was 30.13 years compared to 27.43 years in the non-PPH group (p=0.18). Median gravidity was 3 for both groups (p = 0.60), and median parity was 1 (p = 0.30). Median birth weight was 3,170 g in the non-PPH group and 3,130 g in the PPH group (p = 0.93). Patients with PPH had a significantly lower median gestational age at delivery (38.1 weeks vs. 39.1 weeks, p = 0.04). Cesarean delivery was significantly associated with PPH. Among 200 cesarean deliveries, 23 (11.5%) resulted in PPH, compared to 12 out of 450 (2.7%) vaginal deliveries (p < 0.001). A total of 248 patients had sufficient documentation to calculate APNCU. Of these, 113 received inadequate prenatal care, while 135 received intermediate, adequate, or adequate plus care. PPH occurred in 6.2% of patients with inadequate care and 5.9% of those with intermediate/adequate/adequate plus care (p = 0.93), indicating no significant difference. Conclusion: In this study, adequacy of prenatal care as measured by the APNCU index was not statistically associated with the occurrence of PPH. These findings suggest that quality of prenatal care, rather than quantity alone, may influence PPH risk. Further research with larger samples is needed to confirm these results. This study was limited by a relatively small number of PPH cases (n = 35), reducing statistical power. Additionally, 403 patients lacked sufficient documentation to assess prenatal care adequacy using the APNCU index, highlighting a limitation in the electronic medical records analyzed. The observed PPH rate of 5.4% exceeds the national average (2019), possibly reflecting the implementation of quantitative blood loss (QBL) monitoring in our institution beginning January 2021, in contrast to prior reliance on estimated blood loss (EBL). This underscores the importance of accurate and standardized blood loss measurement. Furthermore, delivery route and gestational age at delivery were statistically significant which highlights the importance of clinical decision-making in labor and delivery.