Introduction
For long, it is known that early and adequate prenatal care is important
to reduce perinatal complications, such as preterm
birth.1, 2 The World Health Organization recommends at
least 8 visits in total and the first visit to take place at 13 weeks
gestational age at latest.3 Early prenatal care is
important to assess the gestational age, which may be helpful later on
in managing preterm birth, prolonged pregnancy or
complications.4 Early antenatal care is also essential
to enable timely screening for anaemia and rubella, to assess Rh and AB0
blood typing, to offer non-invasive genetic testing and to address
potential risk factors such as high body mass index and domestic
violence.5 Furthermore, considering the great impact
of circumstances during pregnancy, timely education of pregnant people
regarding healthy behaviours, including nutrition, supplement intake,
smoking and alcohol cessation and exercise, is similarly
important.5
In the Netherlands, antenatal care is generally accessible to pregnant
people. All expenses, except travel costs, are covered by the basic
health care fund, and specific government arrangements guarantee free
obstetric care for pregnant people without health
insurance.6 Still, in 40% of the births in Rotterdam,
a multi-ethnic city with large social and perinatal health
inequalities,7 antenatal care started only after ten
weeks of pregnancy.8 Previous research pointed at
several predictors for a late antenatal care initiation, including young
age, being single, lower socio-economic position, migration background,
mental health problems, poorer language ability and higher
parity.9-14 Many of these factors are also predictors
of preterm birth.15, 16 Together, these observations
underline the so called ‘Inverse Care Law’, describing that those who
need care the most, have the least access to care.17
Thus far, most studies evaluated a wide range of predictors for late
antenatal care initiation, without discerning between factors that are
and are not modifiable. A potentially important modifiable reason for
late antenatal care initiation is late recognition of the
pregnancy.18, 19 A study in the United States showed
that participants who recognized the pregnancy early (within 6 weeks
after the first day of the last menstrual period) initiated antenatal
care 6 times more often timely (<12 weeks of gestation) than
those with later pregnancy recognition, after adjustment for
socioeconomic variables.18 The aim of this study is
therefore to investigate predictors in timing of antenatal care
initiation; and to assess whether some of these inequalities would be
reduced had everyone recognized the pregnancy early.