Adverse birth outcomes such as infant mortality, low birthweight, preterm birth, and intrauterine growth retardation are related to prenatal care. Furthermore, many adverse birth outcomes lead to adverse psychological, behavioral, and physiological problems in childhood that may continue into adulthood. Rates of infant mortality and preterm delivery are twice as high among African American infants as among white infants born in the US.

The article examines factors that affect access to and use of prenatal care among poor African American women and strategies that may be effective in improving these rates. The primary goal of this literature review is to identify barriers to prenatal care, the limitations of prenatal care in improving pregnancy outcomes among African American women, proposed changes in current prenatal care services, and directions for future research.

In the United States, infant mortality of African Americans is approximately twice that of white infants, while their rate of preterm delivery ranges from two to three times that of whites. From 1973 to 1983, the incidence of moderately low birthweight decreased more among white infants than black infants. Furthermore, during this time, incidence of very low birthweight (<15000g) increased among blacks, while it declined among whites.

The higher rates of low birthweight may be indicative of the higher incidence of preexisting and pregnancy-related conditions among black women such as infections, sickle cell anemia, hypertension, and heart disease. Also, multiple gestation, which increases the risk of low birthweight, is more frequent among black than white women.

Numerous barriers to prenatal care exist for black women. Black women who are impoverished, adolescent, unmarried, have lower level of education attainment, and have additional young children are less likely to seek and obtain adequate prenatal care. A major barrier to a poor black woman is lack of health coverage, particularly private insurance, and other financial hardships connected with receipt of prenatal care. Lack of education may contribute to lack of awareness of pregnancy and the importance of timing prenatal care. Psychological barriers may be more prevalent among black women. Psychological stressors such as depression are frequent among pregnant women, while poverty tends to exacerbate all of the psychological barriers. Also, life stressors, which may increase pregnancy complications, are more common among poor women. Regardless of socioeconomic status, racial discrimination intensified by loss of cultural identity and traditional support system may lead to adverse health and reduced use of prenatal care among black women. Structural and systematic barriers have also been identified. The current structure of prenatal care with its focus on "medicalization of childbirth," which views pregnancy as a pathological condition and relies on medical technological intervention, may lead to feeling of depersonalization and negative attitudes to the use of prenatal care among women. This atmosphere may be exacerbated in public prenatal clinics, sites where most poor women receive their prenatal care. Public clinics are associated with brief and hurried physician visits, long waiting room time, and greater depersonalization than private sources of prenatal care. Thus, structural and systematic barriers may work in unison to persuade a poor black woman from using prenatal care services.

Furthermore, prenatal care may have limited effectiveness to reduce preterm delivery or low birthweight. Precise biological mechanisms leading to preterm and low birthweight are unknown. In order to improve birth outcomes among poor women, particularly black women, systematic changes in our entire socioeconomic structure and not only the health care system are necessary. Without these comprehensive changes, poor black women may not benefit from improvements in access to and quality of prenatal care. Also, high levels of stress are related to unhealthy behaviors, such as alcohol use, smoking, and illicit drug use, among poor minority women. Research has shown that "the adverse effects of smoking and illicit drug use on the fetus may be more pronounced in African American infants."

Although prenatal care may not substantially improve all pregnancy outcomes, significant benefits are associated with prenatal care. It can get women back into the health care system and thus may disclose treatable diseases in the women and provide further health education. However, in order to reach black women, modifications must be made in our current prenatal system. The psychological needs of black women must be addressed within the system and prenatal care should match the needs and risk of the black women. Future research should explore the "knowledge of factors precipitating risk behaviors in African American women may facilitate the development of prenatal care services that more effectively address the underlying psychological affecting maternal health behaviors during pregnancy."

Although significant medical advances have been made to improve outcomes for pregnant women and their offspring, psychological issues confronting pregnant women still need to be addressed. Women need to promote their own health as well as their infants by maintaining healthy behaviors during pregnancy. This is particularly relevant to the African American women who live in impoverished conditions. Thus, we must cultivate a health care system that "restores the right of women and their families to make informed choices about their childbirth and provide the level of support to low income African American women and their children that will increase the odds that they will survive and prosper in a complex and often harsh world."