About a quarter of pregnant women in the US don’t get prenatal care in their first trimester, report says

By Jacqueline Howard, Asuka Koda, CNN

(CNN) — Some women rush to their doctor just days after getting a positive pregnant test, but Dr. L. Joy Baker said she often sees patients for the first time just weeks or even days before they give birth.

“At least once week,” a woman may start prenatal care well into their second or third trimester of pregnancy, said Baker, an obstetrician-gynecologist based in LaGrange, Georgia.

“I accept patients up until delivery, and sometimes there are patients that we have not seen at all, and they are in their third trimester, or they’re even 39 weeks,” Baker said. “I’ve done initial prenatal visits at 39 weeks and the patient delivered a week later.”

Starting prenatal care after the first trimester of pregnancy appears to be a growing yet dangerous trend in the United States, according to a new report.

The report, released Monday by the infant and maternal health nonprofit March of Dimes, says that only about 75% of babies last year were born to mothers who started prenatal care in the first trimester of pregnancy.

“We’ve always known that getting that prenatal care started early is important,” said Dr. Michael Warren, March of Dimes’ chief medical and health officer. He added that now, in the United States, it’s moving in the “wrong direction.”

“For a quarter of women in this country, the first visit is not happening in the first trimester,” he said, which has been part of a four-year decline.

Starting prenatal care early is vital because it “gives us the longest possible window to be able to understand how we can best support the health of that pregnant mom, whether it’s addressing chronic diseases that she might have and making sure those are appropriately managed or identifying risk factors,” Warren said.

Warren identified several systemic barriers that are preventing women from starting or maintaining prenatal care. Areas where there is limited or no access to maternity care, known as maternity care deserts, are one major driving force.

More than a third of counties in the United States do not have an ob/gyn, a family physician or a certified nurse-midwife. These counties also do not have birthing facilities or centers in hospitals, Warren said.

“Those counties are home to over 2 million women of reproductive age and about 150,000 births every year in the United States,” he said. “If you live in one of those counties, you’re going to have to drive farther to get prenatal care, and when your baby is coming, you have longer to go to be able to find a place that can actually deliver.”

A major risk to mom and baby

The latest findings come as no surprise to Baker.

“A lot of times, when I see patients who are second and third trimester, I always ask, ‘What kept you from getting in? What was your barrier?’ They often tell me, ‘I had trouble getting my Medicaid,’ or ‘I was moving around a lot,’ or ‘I had housing insecurity or food insecurity,’” Baker said.

“There are a variety of reasons why folks may present late to care,” she said. “But when they have chronic conditions or even conditions that started in the pregnancy – like preeclampsia or gestational diabetes – the earlier that we know, the better we’re able to treat.”

That’s why inadequate or delayed prenatal care can put women at risk of complications or even death, and it plays a big role in the current state of maternal health in the United States, Baker said.

“As a doctor practicing in a small town, I definitely understand that there are often barriers to care for women who have become pregnant,” she said. “There are also barriers to care for women before they become pregnant, which I think may be even more of an issue.”

Addressing these barriers to care remain vital for improving maternal health, she said, adding that care should start well before pregnancy.

“It’s the one area where we could really make a plan to prevent severe morbidity and mortality,” she said. “I think this is an area we need to divert more resources to.”

For instance, Baker said, she treated a woman who came to her office for a first prenatal visit at 37 weeks, and the patient had high blood sugar levels.

“We were doing just her initial lab work at 37 weeks, and she had a blood glucose of nearly 300,” Baker said, which was a serious concern for the health of both the mother and the baby. A blood glucose level of 200 mg/dL or above is typically indicative of diabetes.

“We basically just needed to induce her labor right away because her sugars were so uncontrolled, which was an independent risk factor for stillbirth and a significant risk to her health, as well,” Baker said.

“Had we seen her early and diagnosed her diabetes prior to pregnancy, we could have treated her, helped her control her sugars and significantly reduce the risk to mom and baby,” Baker said. “Consistent, high-quality care would have been a much better experience for her versus walking into the office one day and then being told to report to the hospital for delivery the next.”

‘Nothing … surprised us’

Inadequate prenatal care can often lead to pregnancy or childbirth complications for both the mother and the baby, including preterm birth.

The new March of Dimes report gives the United States a D+ grade for having a preterm birth rate of 10.4% for the third year in a row.

“Sadly, I actually have to say that there was nothing that surprised us” in the new report, said Divya Sooryakumar, the vice president of programs and impact of the maternal health nonprofit Every Mother Counts, who was not involved in the report.

“One thing that I really appreciated about this year’s report was the bifurcation of the impact on preterm birth by insurance type, because that’s something that we’ve seen for a long time,” Sooryakumar said.

She was glad this year’s report “spelled out very clearly how pregnant people on Medicaid are disproportionately impacted by the maternal health care crisis in this country.”

And many women may delay care because they are not sure whether the care will be fully or partially covered by their Medicaid insurance or other insurance providers.

“Where we need to start is reimbursing prenatal care and postpartum care through Medicaid for what it actually costs to do the work. Historically, that work has been chronically under-reimbursed,” Sooryakumar said. “And it creates an incentive for systems and those delivering care to not actually take Medicaid, and then those populations continue to face the brunt of the disparities in the system.”

This gap in adequate care can be seen in preterm birth rates, according to the new March of Dimes report, which says that between 2022 and 2024, the preterm birth rate among mothers with private insurance was 9.6%. Among mothers using Medicaid, it was 11.7%.

Medicaid covers more than 40% of births in the United States, Warren said.

Barriers to accessing care

For many women, especially those in maternity care deserts, even getting to a provider can be a major roadblock.

Among its other efforts, the nonprofit organization Every Mother Counts supports a group of midwives in New Mexico who serve indigenous patients. Because of the lack of infrastructure in that area, the group’s radius for care is up to a four-hour drive. Some patients who are in labor or need prenatal care will get in their car and drive those four hours for these appointments, Sooryakumar said.

It also may be difficult for patients to be seen by a provider. “We know that there are all sorts of delays due to workforce shortages and shrinkage,” she said. For instance, a report published last year by the Association of American Medical Colleges projects that the nation will face a physician shortage of up to 86,000 physicians by 2036.

Sooryakumar added that the US Supreme Court’s Dobbs decision in 2022, which overturned the right to an abortion, also appears to affect patients’ abilities to see a provider. For instance, some providers in states with more restrictive abortion laws have turned away patients in the first trimester “because there is a fear that if a patient miscarries, it will be labeled as an abortion or investigated as an abortion,” she said.

Another barrier to care can be how safe patients feel to seek it, especially among immigrant, mixed-status or undocumented families. “During times of immigration crackdown, that is when families will delay prenatal care,” Sooryakumar said, referring to it as a cycle.

“In 2018, during the era of family separation and especially now, families go into hiding, and what that means is later and later access to prenatal care,” she said. “So what we’ve been seeing, especially over the last few years, is that all three of these factors – getting to a provider, being seen by a provider, and feeling safe, seeking care – are all systematically breaking down at the same time.”

Incentive and reporting structures for Federally Qualified Health Centers, which provide care to underserved communities, can also play a role in delayed care, Sooryakumar added.

These measures are designed to encourage early prenatal care, but an unintended consequence is that some clinics may be less able or less likely to accept patients who arrive later in pregnancy. As a result, women who seek care in the third trimester can be turned away, Sooryakumar said.

‘That is not acceptable … in 2025’

“Having accessible health care before pregnancy is crucial,” Warren said. “It allows people to receive routine preventive visits, screening for conditions, identification and treatment of chronic diseases.”

Women who have chronic diseases including high blood pressure, diabetes and obesity are at “a greater risk for having a baby born preterm,” he said. And that remains a major driving force as to why the highest rates of preterm birth are concentrated in the Southeast.

“The Southeast is one of those areas where we have higher rates of chronic disease, for example. So it’s not surprising that those preterm birth rates are the way they are,” Warren said, adding that this is compounded by a concentration of maternity care deserts in Southeast counties.

But some states have been successful in improving preterm birth rates.

Warren pointed to Tennessee, where there was a high percentage of women who smoked before and during pregnancy. Smoking is a risk factor for preterm birth.

“They really have worked to make it easier for women to quit smoking and are doing a combination of educational programs and incentives, and work to make sure that it’s easy for them to quit smoking and that they’re supported in that journey along smoking cessation,” he said.

Research has associated the state’s smoking cessation program for pregnant women with better pregnancy outcomes, including a significantly reduced risk of having an infant with a low birth weight.

In the Midwest, Illinois recognized that pregnant women may often face challenges such as poverty or housing and food insecurity, which can impact their access to care.

“They’ve instituted case management programs where they actually have folks who will work with women during pregnancy, particularly women who are at high risk of having worse pregnancy outcomes,” Warren said.

But to address the overall maternal health crisis, Warren said, there must be a national effort to ensure that women have insurance coverage across their lives and the country must “maintain a really robust public health infrastructure.”

He warned that should the trend of inadequate prenatal care continue, more mothers will not be there to celebrate their babies’ first birthdays.

“Every year in this country, we lose over 20,000 babies in [the] first year of life. We lose over 600 moms, either during pregnancy or delivery, or during that first year postpartum,” Warren said. “That is not acceptable in the United States in 2025, and unless we change our course, those numbers are not going to get better. They’re going to get worse.”

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