Objective: To test the hypotheses that, in a health system with few external barriers to care, women with no prenatal care (NPC) have higher rates of nuclear family dysfunction and disproportionate amounts of adverse neonatal outcomes compared with women with prenatal care. Design: Case-control study. Setting: Indian Health Service system. Patients: Nuclear families of women not seeking prenatal care compared with those who did seek prenatal care. Main Outcome Measures: Dysfunctional outcome

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... sures in nuclear families were children adopted, placed, or under protective surveillance; mothers denying pregnancy, being abused, or attempting suicide; and parents with alcoholism. Neonatal outcome measures were low birth weight and neonatal intensive care days. Results: Dysfunctionalmarkersoccurredsignificantlymore frequently in families of women with NPC than in families of women with prenatal care (57% of NPC and 12% of control families; McNemar odds ratio, 14; 95% confidence interval, 4.7-41.6). Neonatal outcome in this Native Ameri-canpopulationshowedthatwomenwithNPChadonly2.6% (58/2222) of the total births but accounted for 11% of the low-birth-weight infants (Ͻ2500 g), 18% of the very-lowbirth-weight infants (Ͻ1500 g), and 24% of the level II and 41% of the level III newborn intensive care days. Conclusions: Women not seeking prenatal care in a system with few external barriers to care have significantly more family dysfunction (PϽ.001) than women seeking prenatal care. Infants of women with NPC generated a disproportionate amount of adverse neonatal outcome. The combination of NPC and family dysfunction was more predictive of adverse neonatal outcome than was NPC alone.