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Chapter Barriers to the Use of Prenatal care Interventions to increase the use of prenatal care should be based on a firm understanding of why some pregnant women do not obtain adequate prenatal supervision. As a step in that direction, this chapter outlines a variety of barriers to care that many women face. Four categories of obstacles are discussed: 1. a set of financial barriers ranging from problems in private insurance and Medicaid to the complete absence of health insurance; 2. inadequate capacity in the prenatal care system relied on by low- income women: 3. problems in the organization, practices, and atmosphere of prenatal services themselves; and 4. cultural and personal factors that can limit use of care. FINANCIAL BARRJERS The average bill for having a baby is about $4,300 a figure that includes hospital and physician charges spanning prenatal care, labor and delivery services, a postpartum checkup, and hospital services for the newborn.*) Considering that the typical annual income of a couple in their *This figure includes both complicated and uncomplicated pregnancies and deliveries as well as costs associated with health problems in some newborns. 54

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BARRIERS TO THE USE OF PRENATAL CARE / 55 ~ ~ No maternity coverage (15%) \~ ~ // Medicaid (17%) CHAMPUS/Other (4%) Individual private (3%) Private group (61 %) FIGURE 2.1 Percentage distribution of all new mothers by insurance coverage at time of delivery, United States, 1985. SOURCE: Gold RB, Kenney AS and Singh S. Paying for maternity care in the United States. Fam. Plan. Perspect. 19:19~211, 1987, table 12. early 20's the prime childbearing yearsis about $19,800,2 pregnancy and childbirth can be a great financial burden. It is therefore not surprising that financial status, and health insurance coverage in particular, plays a major role in determining whether or not prenatal care is secured. Despite the importance of health insurance, an increasing number of Americans some 37 million at present- are without any. Even those who do have insurance may have little or no coverage for maternity care. In this section, three aspects of the insurance problem are discussed: (1) gaps in private insurance coverage for maternity services; (2) the role of Medicaid in helping some, but not all, poor women secure prenatal care; and (3) the problems of women with no health insurance at all. An excellent analysis of these issues has been published by the Alan Guttma- cher Institute (AGI).3 The sections that follow draw heavily on that report. To provide background and context for these sections, Figure 2.1 shows the type of maternity coverage reported for women who gave birth in 198S. Although these data reflect payment source at time of delivery and not payment source for prenatal care exclusively, the two sources generally correspond quite closely. Private Insurance Privately insured women are more likely to obtain adequate prenatal care than uninsured or Medicaid-enrolled women. The reasons for this differential include the demographic characteristics of privately insured

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56 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS income, more education, and so on), the greater . . . . . . In women (higher availability of providers to women with private insurance twn~cn turn, is related to more generous reimbursement patterns and other factors), and the ability of these women to pay in advance for selected prenatal services. Some 41 million women (73 percent of women between the ages of 15 and 44) are now covered by private health plans.4 Most private coverage derives from group insurance, obtained by women on their own or through their spouse or family as an employment benefit. Since the enactment of the Pregnancy Discrimination Act in 1978, employers have been required to offer maternity care benefits in the same manner as other medical benefits. As a result, many more private plans now include maternity coverage. In 1977, only 57 percent of employees with new health insurance policies had maternity care benefits, but by 1982 the number had increased to 89 percents Many women do not have access to employer-based group coverage because they or their spouses are unemployed or work for employers who do not offer health benefits. Moreover, if the cost to the employee is too high, the mere availability of an employer-based group insurance plan does not ensure enrollment. In fact, even enrollment does not guarantee that a woman will be adequately covered for maternity care or protected from high cost-sharing burdens. Gaps in coverage, imposition of waiting periods that may exclucle women already pregnant, recent cutbacks in dependent coverage under some plans, the growing reluctance of employers to help finance dependent coverage, shifts and increases in premiums, and deductible and copayment requirements have all placed new and complex burdens on women and young families. A few of these problems in private insurance are discussed in more detail below. Eligibility for Coverage Although over 80 percent of all privately insured Americans under age 65 are insured through their employers, over half of uninsured individuals in 198S were in families where at least one member had a full-time job.6 Whether employers furnish insurance depends on their financial status, on how highly they choose to compen- sate their work force, or both. Small businesses and employers of low-paid or part-time nonmanufacturing and seasonal workers are less likely to furnish health insurance or to underwrite the cost of premiums.7 Since women are disproportionately represented in these categories of workers, they are less likely to be insured.8 Firms that pay low wages are substantially less likely to offer subsidized health insurance as part of their employees benefit packages, even though it is lower paid employees who are particularly in need of the subsidy.9 Moreover, in recent years employers who do subsidize employee coverage have begun to reduce or

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BARRIERS TO THE USE OF PRENATAL CARE in some instances eliminate their contributions.~ Th 57 is trend has particu- larly serious implications for women employed at minimum wage jobs, since the minimum wage has remained fixed and unadjusted for inflation since 1980. Women who are not in the labor force are almost entirely clependent for private insurance on their spouses' family coverage through employers' plans. Thus, women who are not married and are unemployed or marginally employed are significantly more likely than women who are married or employed full-time to have no private insurance. Similarly, nonworking women in poor and near-poor families are particularly likely to be without private insurance because their spouses, like low-income workers generally, tend to have no employer-based insur- ance, to have employer-based insurance covering the working spouse only, or to have access only to coverage that is too costly to buy. The increase in single-parent families (whether headed by a divorced or separated parent or a never-married parent) has also contributed to the growing number of families without private coverage. Single-parent families are three to four times more likely to be completely uninsured than two-parent families. ~ ~ Even women who have coverage may face long waiting periods before benefits can be obtained. The AGI report notes that: . . . 58 percent of full-time employees participating in employment related health insurance programs- including about 20 million women of reproductive age belong to plans that require a waiting period. . . 18 percent [of such employees] belong to plans that impose waiting periods of 10 months or more, thus eEectively precluding any reimbursement for care during pregnancy. Scope and Depth of Coverage Employees and families with private insurance are increasingly likely to be covered less comprehensively than they were in the past. The Pregnancy Discrimination Act of 1978, which mandates that private insurance plans provide coverage of routine mater- nity care, does not apply to employers of fewer than IS persons, and not at} states have enacted remedial legislation of their own to close this gap. Furthermore, such state laws, where applicable, do not apply to employers who self-fund their insurance coverage. As a result, some five million women have insurance plans with virtually no coverage for maternity care. 13 In addition, insurers have varying policies regarding coverage of labo- ratory, X-ray, and other supplemental services such as nutritional coun- seling. Some private insurance plans either fad] to cover benefits that may be important to pregnancy outcomes or impose limits on coverage unrelated to medical need. For example, in 198S only US percent of private plans covered home health care.~4

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58 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS Patient Cost-Sharing Except for prepaid health plans, first-dollar coverage of prenatal and delivery costs is seldom included in private health insurance packages. Pregnant women usually pay an initial deductible, and physicians generally require a relatively large payment in advance for prenatal care. At the time of delivery, pregnant women may also be asked to pay a percentage of hospital room charges (typically 20 percent, sometimes more). Recent employer cost-containment strategies have included significant increases in deductibles and coinsurance obligations, which pass the cost directly on to the individual. Although adequate data on out-of-pocket costs for pregnancy and childbirth among privately insured women are unavailable, it is apparent that, for some women, the required cash payments are significant and burdensome. Medicaid The Medicaid program is the largest single source of health care financing for the poor and is generally believed to be primarily responsible for the increased use of medical services by low-income individuals since its enactment in 1965. With regard to prenatal care specifically, the National Center for Health Statistics' (NCHS) nasality data from 1969 (the first year in which NCHS compiled such data) and 1980 show significant improvements in the use of prenatal care shortly after Medicaid was enacted and 11 years later, as evidenced by increases in the proportion of pregnant women seeking care in the first trimester (Table 1.11~. Since 1980 there has been little improvement, as discussed in Chapter 1. Table 1.11 shows that the greatest increase in use of prenatal care between 1969 and 1980 was among black women. In 1969, 43 percent of black women and 72 percent of white women initiated prenatal care in the first trimester of pregnancy. These figures increased to 63 percent for black women and 79 percent for white women in 1980. These differential gains may be due to the fact that higher proportions of black women were living in poverty and enrolled in Aid to Families with Dependent Children (AFDCthat is, welfare) during this period, and AFDC enrollment has traditionally included eligibility for Medicaid benefits. These findings underscore the special role of Medicaid in increasing minority access to prenatal care. Selected state reports confirm the importance of Medicaid in securing prenatal services. For example, Norris and Williams examined the impact of Medi-Cal (Califomia's Medicaid program) on perinatal outcomes in California and found major differentials in prenatal care use among selected ethnic groups between 1968 and 1978, a period of significant Medi-Cal expansion. In 1968, Medi-Cal reimbursed costs for 13 percent of all California births; in 1978, it reimbursed 27 percent. Although the proportion of women receiving care in the first trimester increased for all

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BARRIERS TO THE USE OF PRENATAL CAM 59 groups in the state during that period (whether enrolled in Medi-Cal or not), the increase was greatest among enrolled women. For example, among white (non-Spanish surname) women on Medi-Cal, 46 percent began prenatal care during the first trimester in 1968; by 1978, that figure had grown to 65 percent a gain of almost 20 percentage points. Among white (non-Spanish surname) women not enrolled in Medi-Cal, the improvement was more modest: 76 percent began care in the first trimester in 1968 versus 82 percent in 1978.~5 Despite such favorable trends, data also show that women covered by Medicaid do not obtain prenatal care as early in pregnancy or make as many visits to providers as women with private insurance. For example, using data from New York City in 1981, Cooney compared delayed care among Medicaid recipients with delayed care among women with less than 12 years, education (a proxy measure for low income) who had private insurance. In 23 out of 30 subgroups defined by race, marital status, and age, more Medicaid recipients obtained delayed care than women with third-party insurance. Similarly, a 1986 survey of over 2,000 women in Texas found that 85 percent of women with private health insurance began prenatal care in the first trimester versus 40 percent of women enrolled in Medicaid; about S percent of privately insured women hac} five or fewer prenatal visits versus 2S percent of women in Medicaid.~7 Data from the National Survey of Family Growth and several other state surveys confirm this general picture. i9 It is important to add, however, that few of these studies analyzing use of prenatal care by insurance coverage control for the changing eligibility status of women over the course of a pregnancy. In particular, a woman listed as Medicaicl-enrolled at the time of delivery may not have become eligible for the program until just before delivery. If, in adclition, she delayed beginning prenatal care, she will be counted as a Medicaid- enrollecl woman who began care late, even though her delay in beginning care and her Medicaid status may or may not have been related. Despite this methodological problem, at least three factors suggest that these studies are accurate in their finding that Medicaid is associated with more limited prenatal care than is private insurance. First, as discussed later in this chapter, the Medicaid enrollment process is so time-con- suming that a woman may be well into her pregnancy before her eligibility is established. Thus, she may have been financially unable to obtain care earlier. Second, Medicaid-insured women rely more heavily on clinics for prenatal care than do women with private insurance, and in many communities these clinics are overburdened and unable to schedule appointments promptly.20 Also, the number of physicians accepting Medicaid-enrolled pregnant women has always been limited and in some areas it is decreasing. (These issues of system capacity are taken up later in

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60 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS TABLE 2.1 Annual Visits to the Doctor and Other Characteristics of Poor Womena with an Infant Age 3 Months or Younger, National Health Interview Survey, 1978, 1980, and 1982 Poor Women Uninsured Medicaid Other Insurance Characteristic (N= 71) (N= 98) (N= 132) Annual visits to doctor (no.) 11.0 12.6 13.1 Black (%) 19.7 42.9 18.2 Community type (%) Central city 28.2 48.0 28.0 Rural 56.3 19.4 40.2 Region (%) Northeast 9.9 23.5 17.5 South 53.5 24.5 43.9 North central lS.S 31.6 25.0 West 21.1 20.4 13.6 Education (years) 10.9 10.6 11.7 Family income ($ 1982) 1,672 1,438 2,429 Marital status and age (%) Unmarried, 17-19 9.9 21.4 3.8 Unmarried, 20+ 8.5 45.9 6.1 Married, 17-19 12.7 5.1 12.1 Fair or poor health (%) 14.1 17.3 12.1 NOTE: Insurance status reflects coverage at some time during the interview year. It was not possible to identify when during the pregnancy coverage of a given type began. Also, this sample included poor women with an infant age 3 months or younger at the ume of the interview. Their reported annual visits to a doctor largely reflect prenatal care; however, a postpartum visit and visits not directly related to the pregnancy were also included in each woman's total count of visits. aReal income per family member of less than $3,500 in 1982 dollars. SOURCE: 1978, 1980, 1982 National Health Interview Surveys; calculations by J. Hadley for the Once of Technology Assessment, U.S. Congress. this chapter.) Finally, women on Medicaid are, by definition, at the bottom rung of the economic ladder and are characterized by numerous other demographic factors associated with insufficient prenatal care, including having limited education, being unmarried, under 20, and in fair or poor health. (See Table 2.1, although note that the table only reports on poor women; if Medicaid-enrolled women were compared with all women, evidence of their disadvantage would be more striking.) Given these attributes of the Medicaid population, health insurance alone is unlikely to close the gap between their use of health services and that of more affluent women with private coverage.

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BARRIERS TO THE USE OF PRENATAL CARE 61 It is not as clear how Medicaid-enrolled women compare with uninsured women in their use of prenatal care. Some studies find that uninsured women receive quantitatively more adequate care than Medicaid-enrolled women. For example, a 1986 survey of 517 births in Rhode Island found that 84 percent of women with private insurance, 70 percent of uninsured women, and 57 percent of Medicaid-insured women obtained adequate prenatal care.2i By contrast, a General Accounting Office (GAO) study of 1,157 pregnancies found that both Medicaid-enrolled and privately in- sured women began care earlier in pregnancy and saw a provider more frequently than did women with no insurance.22 Hadley examined the use of prenatal care by pooling data from the 1978, 1980, and 1982 Health Interview Surveys. He found that when analysis is confined to poor women only that is, when poverty is held constant- Medicaid-enrolled women made more visits to a doctor than uninsured women, though less than privately insured women (Table 2.19. The picture that emerges from these many data sets is that Medicaid has improved access to prenatal care for poor women. Enrolled women, however, still do not obtain as much prenatal care as women with private insurance, whether measured by trimester in which care was begun or number of visits. On the other hand, enrolled women probably obtain more prenatal care than uninsured women (when poverty is held con- stant), although the data on this relationship are mixed. Despite the importance of Medicaid in helping many low-income individuals (including pregnant women) gain access to health care, a substantial proportion of the poor is not covered by this program. In fact, in 1988 the average income eligibility ceiling for Medicaid was only 49 percent of the federal poverty level.23 Though designed to meet the medical needs of the disadvantaged, Medicaid in 1985 "reached less than half the people under the federal poverty {eve! in 36 states and in 22 of those states it reached less than a third."24 In addition, the proportion of the poor covered by Medicaid has decreased: it is estimated that in 1976, 6S percent of the poor were covered by Medicaid; in 1984, the comparable figure is 38 percent.25 Aware of the inadequate coverage of Medicaid for many pregnant women and children, Congress has recently expanded eligibility for Medicaid by means of the Deficit Reduction Act of 1984, the Consolidates! Ominibus Budget Reconciliation Act of 198S, the Omnibus Budget Reconciliation Acts of 1986 and 1987, and the Medicare Catastrophic Coverage Act of 1988. Two of the most important reforms in these laws are (1) removing the consideration of"household composition" from eligibil- ity determinations for pregnant women and (2) severing the link between Medicaid and AFDC. The 1986 law allowed states for the first time to offer Medicaid to poor children (up to age S) and to pregnant women with

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62 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS incomes up to 100 percent of the federal poverty level, regardless of their eligibility for welfare or cash assistance under a state's AFDC guidelines. Two-thirds of the states chose to adopt this expansion, and the 1988 law requires all states to have such coverage by 1990. The 1987 law permits states to expand eligibility even further for poor children (up to age 1) and for pregnant women with incomes up to 185 percent of the federal poverty level. As of June 1988, six states had done so.26 The importance of separating Medicaid from welfare merits emphasis. It affords states the opportunity to increase Medicaid eligibility for particular subgroups, and to receive federal matching funds, without increasing AFDC program costs. Also available to states are two other important means of severing health care financing from welfare in certain ways and for certain groups: "medically needy" programs and coverage of two-parent families with an unemployed parent (so-called AFDC-UP or Medicaid-UP programs). These option and the newer ones noted above are described by the American Hospital Association in Medicaid Options: State Opportunities and Strategies for Expanding Eligibility.27 Congress is considering additional reforms to increase Medicaid enroll- ment among eligible pregnant women and children. For example, a recent legislative proposal would expand Medicaid to help finance casefinding and other activities to identify eligible individuals and assist them in enrolling in the program. The legislation would also require states to maintain an adequate number of obstetrical providers in the program. uninsured women Despite economic recovery and rising employment, lack of health insurance has become an increasingly important social and economic problem in the United States in recent years. By the mid-1980s, more than 37 million Americans were completely uninsured. Women of childbearing age are disproportionately represented among the uninsured.28 An estimated 26 percent of women of reproductive age (14.6 million) have no insurance to cover maternity care, and two-thirds of these (9.5 million) have no insurance at all. Of poor women, 35 percent are completely uninsured. As one might anticipate, the women that are most likely to be uninsured are the most likely to be poor those who are black or Hispanic, poorly educated, working in low-paying jobs or unemployed, unmarried, or in their early 2o,s.29 Poor women with no insurance face significant obstacles to obtaining prenatal care. Their options are limited to charity care at the hands of evicting providers or care in public health clinics and other settings usually financed by public funds. As the section on system capacity below notes,

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BARRIERS TO THE USE OF PRENATAL CARE 63 in many areas these clinics are so overburdened that prompt entry into care can be very difficult. Provision of free care in clinics and other settings can soften the effects of being uninsured. For example, the GAO study referred to earlier reported that: . . . about 86 percent of the interviewees at Cooper Green Hospital in Birmingham, Alabama, where free prenatal care is available through the public health department, were uninsured mothers. Yet, none of these women who received insufficient care cited lack of money as their most important barrier. By contrast, about 27 percent of the women delivering at Los Angeles County-USC Medical Center who obtained insuffi- cient care cited lack of money as the most important barrier. About 94 percent of the births at the hospital were to uninsured mothers. Los Angeles County clinics charge $20 per visit for the first seven prenatal care v~sits.30 It is not known how extensive the availability of free care is nationally or what recent trends have been, although a recent survey suggests that state maternal and child health agencies are able to finance only a small portion of the prenatal care needed by uninsured women- those most likely to seek free or reduced cost care.30a Unfortunately, the proportion of women age 15 to 44 who have no health insurance is likely to grow. Women increasingly work in industries least likely to offer health insurance (such as service and retail jobs); they are also increasingly likely to work part-time, which usually carries no health insurance benefits.3i Other reasons were noted earlier: growing gaps in the employer-based insurance system and the decreasing propor- tion of the poor covered by Medicaid. Although expansions of Medicaid will help finance care for some portion of uninsured women, the problem of absent health insurance has outstripped the remedial steps taken thus far. To sum up, three major themes emerge from the extensive data on the relationship between use of prenatal care and the availability of private insurance, Medicaid, or no insurance. First, women with private insurance are more likely to obtain sufficient prenatal care than those with Meclicaid coverage or no insurance, although there are troubling gaps in private insurance coverage. Second, Medicaid has undoubtedly increased access to prenatal care for low-income individuals, but many poor women are not covered by the program, particularly in the first months of pregnancy. Third, a significant number of women have no insurance at all and must depend on charity care, publicly financed clinics, or other resources to obtain prenatal services. The size of this last group is likely to expand. INADEQUATE SYSTEM CAPACITY Inadequate capacity in the maternity care system often used by low- income women constitutes a second barrier to use of prenatal care. This

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64 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS section outlines two closely related aspects of the capacity issue: first, inadequate numbers of, and long waiting times for appointments at, facilities such as Community Health Centers and health department clinics- settings that have traditionally provided prenatal care to those unable or unwilling to use the private care system; and second, problems concerning the availability of maternity care providers including the uneven distribution of physicians nationally, the unwillingness of some physicians to care for Medicaid-enrolled pregnant women, and the mal- practice problem. .Servir:es in Organized Settings Women with limited financial resources, especially women with neither public nor private health insurance, frequently seek prenatal care in so-called "organized settings," as distinct from private physicians in office-based practices. These settings include hospital outpatient depart- ments, Community Health Centers and Migrant Health Centers, public health departments, Maternity and Infant Care projects, and school-based prenatal services. Several national surveys confirm that these settings are important sources of care for poor women and for young, unmarried, black, or Hispanic women the same groups at risk for inadequate use of prenatal care. For example, the 1982 National Survey of Family Growth (NSFG) revealed that, although private doctors are the major source of care for both poor and nonpoor women (S4 and 83 percent, respectively), clinics are much more important for poor women (that is, women with incomes of less than 150 percent of the fecleral poverty level). About 39 percent of poor women used clinics, compared to 12 percent of nonpoor women. The NSFG also showed that, among pregnant women, about 36 percent of Hispanic women, 4S percent of black women, 42 percent of women under age 20, and 47 percent of unmarried women went to a clinic for their first prenatal visit, as compared with about 10 to IS percent of white, older, and married women.32 Women enrolled in Medicaid were particularly inclined to seek prenatal care at clinics: 60 percent of women whose delivery was paid for at least in part by Medicaid obtained prenatal care at a clinic versus 21 percent of all women.33 The 1980 National Medical Care Utilization and Expenditures Survey (NMCUES) also shows that poor, minority, and single pregnant women rely heavily on clinics for prenatal care.34 The special value of these clinics these organized settingsstems from at least three factors. First, as just noted, they typically provide prenatal care to uninsured or Medicaid-enrolled women. Second, the poor, the very young, and persons not part of mainstream culture often need intensive health education and require assistance in areas beyond medical care, such

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BARRIERS TO THE USE OF PRENATAL CARE 77 her pregnancy and toward prenatal care, her knowledge about such care and whether she sees it as useful, her cultural values and beliefs, a variety of other personal characteristics often called life-style, and certain psycho- logical attributes. This section describes the role of these factors in the use of prenatal care, but it is important to emphasize at the outset that most research on personal barriers does not control for the confounding influence of the prenatal care system itself. That is, little effort has been macle to assess the nature and extent of personal barriers to care in different types of prenatal settings. Attitudes toward pregnancy that may influence efforts to seek prenatal care include whether the pregnancy is planned or unplanned and whether the woman views her pregnancy positively or negatively. Many studies have found that later entry into care and fewer visits are associated with unplanned pregnancy and, similarly, with negative views of a current pregnancy.93 These attitudes may influence prenatal care in three ways. First, women who did not plan their pregnancy may be less aware of the signs of pregnancy and therefore may recognize their pregnancy later. Second, women who view their pregnancies negatively may delay prenatal care while they decide whether to continue the pregnancy. Finally, an unplanned pregnancy is likely to evoke ambivalent feelings, even in women who decide to continue the pregnancy. This ambivalence may result in late entry into or sporadic use of prenatal care. Here it is important to adct that in the United States, more than half of all pregnancies are unplanned.93a Given the evidence that unplanned preg- nancies are associated with late entry into prenatal care, as noted above, and that the magnitude of unplanned pregnancy in this country is great, it is reasonable to conclude that more extensive use of family planning services would result in reduced rates of late entry into prenatal care. Attitudes toward prenatal care itself are also influential. Not all women believe that prenatal care is important and worth the effort to seek it out.94 Some believe that pregnancy is a normal event not needing medical supervision, or that care is needed only if a pregnant woman feels ill; a few women may actually be unaware of what prenatal care is. Previous, unsatisfying experiences with prenatal services may also act as a deterrent. The provider practices and clinic policies outlined above no doubt leave some women with a negative view of prenatal care, reluctant to seek it out in subsequent pregnancies. Studies that have assessed the relationship between attitudes about prenatal care and onset of care show that women who believe the service is important and should be initiated early are more likely to begin care in the first trimester than those attaching less importance to early care.9596 The predictive value of positive attitudes toward prenatal care should not be overestimated, however. Oxford et al. noted that, among a sample of women who began care in the third

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78 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS trimester, i2 percent reported that they thought prenatal care should begin during the first few weeks of pregnancy.97 Not knowing the signs of pregnancy is also related to use of prenatal services. Studies report that between 16 and 33 percent of women who received insufficient care did not know the signs of pregnancy.9~0i Cultural values may affect efforts to seek out prenatal care. Among some cultures, pregnancy is regarded as a healthy condition not requiring medical treatment or a physician's advice.~02 Furthermore, the perception of what constitutes a health problem may vary between patient and provider. In one study, for example, low-income, primarily black women characterized high-risk behavior as not taking prenatal vitamins and catching the flu, but having more than five children or a previous low birthweight infant were not viewed as conditions constituting risk.~03 Fear as a barrier deserves special comment. There may be at least four types of fear: fear of providers or medical procedures, fear of others' reactions to the pregnancy, fear that one's illegal status in the country will be discovered, and fear that such health-compromising habits as substance abuse or smoking will be uncovered and pressures to change brought to bear. With regard to the first fear, a survey of women who had received no prenatal care found that S2.4 percent indicated fear of hospitals, doctors, or procedures as a primary reason for not seeking care.~4 In her in-depth interviews with disadvantaged women who had suffered an infant death, Boone found that "fear of doctors and nurses represented the single most important factor in their perception of health care providers as inac- cessible."~05 Adolescents are particularly likely to cite fear as a reason for not seeking early care. While some pregnant adolescents fear medical procedures, many also fear the pregnancy itself and parental response. A postpartum teenager who delayed care explained, "When I went to the doctor I was 6i months I found out when I was 8 weeks. I didn't go right away because it took me that long to tell my mom."~06 For teenagers who may be eligible for Medicaid during a pregnancy, concerns about confidentiality may be significant. Although procedures vary widely, most states do not have Medicaid policies and practices that protect teenagers' confidentiality. States generally provide a family with only one Medicaid card, which forces teenagers to ask their parents for use of the card before seeking services. i07 Unless they are assured confidentiality, adolescents may choose to protect their secret rather than seek prenatal care. Another group for whom fear can be a major barrier to prenatal care is illegal immigrants, who may not seek care because they are afraid that they will be reported to the Immigration and Naturalization Service (INS) and eventually deported.~08 i09 While reporting is not routine in a clinic, the mere possibility can be a sufficient deterrent. In Los Angeles County, for

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BARRIERS TO THE USE OF PRENATAL CARE 79 example, the board of supervisors recently voted to require all persons requesting free or reduced-cost health services to apply first for Medi-Cal, which, in turn, requires completing a form that is sent to the INS. While the policy never went into effect because of a court injunction, it created substantial anxiety among undocumented families. A CHC pediatrician in Los Angeles County reported that the fear generated by the proposal led to an immediate decrease of SO percent in the number of children attending his clinic.~ Pregnant women who are aware that their life-styles place their health and that of their babies at risk may also fear seeking care because they anticipate sanction or pressure to change such habits as drug and alcohol abuse, heavy smoking, and eating disorders. Substance abusers in partic- ular may delay care because of the stress and disorganization that often surround their lives, and because they fear that if their use of drugs is uncovered, they will be arrested and their other children taken into custody. The issue of drug abuse during pregnancy deserves additional comment. The Chao et al. study in Harlem found that women with insufficient prenatal care were far more likely to report use of heroin, cocaine, or both than women who obtained care early in pregnancy. Poland et al. found that 31 percent of a group of women with inadequate prenatal care abused drugs, mainly heroin, compared with 7 percent of women with more adequate care. Numerous reports detail alarming increases in the proportion of women, including pregnant women, who abuse heroin and cocaine and the resulting rise in the number of babies born with varying degrees of addiction. For example, from January through November 1987, 142 drug-addicted babies were born at a hospital located in a low-income area of Washington, D.C. In 1986, by contrast, there had been S5 such births, and in 1985, 19.~3 Drug abuse among pregnant women has become especially alarming recently because of the Lightened risk that these women carry the human immunodeficiency virus (HIV, cause of AIDS), which can be passed on to the developing baby. In some areas of New York City, for example, between 4 and S percent of pregnant women are estimated to be infected with the virus.~4 Homelessness is also associated with poor use of prenatal care. Chavkin et al. compared the use of prenatal services among women living in New York City hotels for the homeless, women living in the city's low-income housing projects, and all other city residents. Forty percent of the hotel residents studied who had given birth between 1982 and 1984 had received no care at all, versus IS percent of the housing project group and 9 percent of the citywide group. Only 30 percent of the hotel residents had made seven or more visits, versus S8 percent of the housing project group and 68 percent of the citywide group. Unfortunately, homelessness has

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80 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS increased in recent years, and the majority of homeless families are single-parent households headed by women.~5 Having friends and family to offer emotional support and tangible assistance and having well-developed skills in overcoming isolation, may minimize or eliminate barriers to prenatal care; lack of these assets may constitute an impediment to attaining services. Women vary in the amount of these resources and in their ability to adapt in a stable and organized manner to such major changes in life as pregnancy. Several studies suggest that when emotional support is presentpositive interest in the pregnancy by the father, for example, or the presence of someone with whom to share the knowledge of pregnancy the probability of using prenatal care increases. In the absence of such support, particularly in combination with general social isolation, the likelihood of using prenatal care de- creases.~8 Similarly, lack of close ties to family and friends may limit use of prenatal care. The importance of these individuals as sources of information about specific clinics or services is well known; if such networks are in disrepair, it will be harder for a woman to connect with needecl care. Stress may decrease a woman's ability to seek prenatal care. For some women, the pressures of daily life are such that prenatal services are of low priority. A study of more than 2,000 women in Massachusetts found that women with inadequate care were significantly more likely than women with adequate care to report being very worried or upset during the pregnancy due to lack of money, problems with the baby's father, housing difficulties, lack of emotional support, and related burdens.~9 Such factors as depression and, in particular, denial have also been associated with poor use of prenatal care. Although denial that one is pregnant can occur in women of any age, it is often reported in studies of pregnant adolescents. Denial in adolescence often begins as the belief that one is not likely to get pregnant ("It won't happen to me") and continues into pregnancy ("I did not want to accept the fact that I was preg- pant". i2i Denial is withholding information from oneself; conceal- ment, a related behavior, is the withholding of information from others. Furstenberg reports that one-half of 404 adolescents studied clid not tell their parents that they were pregnant for several months. In most cases, the adolescents' mothers either learned of the pregnancy from others or detected it themselves. The prevalence of denial and concealment in adolescents is related to embarrassment about their changing bodies, reluctance to share personal information about their sexuality, lack of knowledge about where to obtain birth control, confusion about the safety and proper practice of contraception, fear of parental disapproval and punishment, and, as noted earlier, fear of pelvic examinations and other medical procedures.~23

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BARRIERS TO THE USE OF PRENATAL CARE TABLE 2.2 Barriers to the Use of Prenatal Care 81 I. Sociodemographic correlates Poverty Inner-city or rural resident Minority Under 18 or over 39 Higher parity Non-English speaking Unmarried Less than high school education II. System barriers . . . . Inac equates In private Insurance policies (waiting periods, coverage limitations, coinsurance and deductibles, requirements for up-front payments) Absence of either Medicaid or private insurance coverage of maternity services Inadequate or no maternity care providers for Medicaid-enrolled, uninsured, and other low-income women (long wait to get appointment) Inadequate transportation services, long travel time to service sites, or both Difficulty obtaining child care Poor coordination between pregnancy testing and prenatal services Inadequate coordination among such services as WIC and prenatal care Complicated, time-consuming process to enroll in Medicaid Availability of Medicaid poorly advertised Inconvenient clinic hours, especially for working women Long waits to see physician II. System barriers (Continued) Language and cultural incompatibility between providers and clients Poor communication between clients and providers, exacerbated by short interactions with providers Negative attributes of clinics, including rude personnel, uncomfortable surroundings, and complicated registration procedures Limited information on exactly where to get carephone numbers and addresses III. Barriers based on beliefs, knowledge, attitudes, and life-styles Pregnancy unplanned or viewed negatively, or both Ambivalence Signs of pregnancy not known or recognized Prenatal care not valued or understood Fear of doctors, hospitals, procedures Fear of parental discovery Fear of deportation or problems with the Immigration and Naturalization Service Fear that certain health habits will be discovered and criticized (smoking, eating disorders, drug or alcohol abuse) Selected life-styles (drug abuse, homelessness) Inadequate social supports and personal resources Excessive stress Denial or apathy Concealment

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82 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS SUMMARY Table 2.2 summarizes the many barriers to use of prenatal care discussed in this chapter, as well as the sociodemographic correlates of prenatal care use defined in Chapter 1. As this daunting list makes clear, many factors that impede use of prenatal care are external to women themselves; they are centered primarily in the financial underpinning of the prenatal care system and in the capacity and practices of various service networks. The pervasive influence of poverty is noteworthy- many of the barriers are strongly associated with low income. The list also helps to show that women's beliefs, knowledge, attitudes, and feelings influence their use of prenatal services, as do such behaviours and conditions as substance abuse and homelessness. REFERENCES AND NOTES Alan Guttmacher Institute. Blessed Events and the Bottom Line: The Financing of Maternity Care in the United States. New York, 1987, p. 18. 2. U.S. Bureau of the Census. Money income of households, families and persons in the United States: 1984. Current Population Reports. Series P-60, No. 151, 1986, table 31. 3. Alan Guttmacher Institute. Op. cit. Also published by the Alan Guttmacher Institute as a companion volume is The Financing of Maternity Care in the United States. New York, 1987. 4. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 20. 5. Gold RB and Kenney AM. Paying for maternity care. Fam. Plan. Perspect. 17:103-111, 1985. 6. Chollet D. A Profile of the Non-Elderly Population Without Health Insurance. Washington, D.C.: Employee Benefit Research Institute, 1987. 7. Ibid. 8. Gold RB and Kenney AM. Op. cit. 9. AS Hansen, Inc. Health Care Survey, January 20, 1986. In Medical Benefits. Charlottesville, Va.: Kelley Communications, 1986, pp. 1-2. 10. Wilensky G. Parley P. and Taylor A. Variations in health insurance coverage: Benefits vs. premiums. Milbank Mem. Fund Q. 62: 134-155, 1984. 11. Sulvetta M and Schwartz C. The Uninsured and Uncompensated Care. Washing- ton, D.C.: National Health Policy Forum, 1986. 12. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 22. 13. Ibid., p. 21. 14. U.S. General Accounting Office. Health Insurance: Comparison of Coverage for Federal and Private Sector Employees. Pub. No. GAO/HRD-87-32BR. Washing- ton, D.C.: Government Printing Office, 1986. 15. Norris ED and Williams RL. Perinatal outcomes among Medicaid recipients in California. Am. J. Public Health 74:1112-1117, 1984. 16. Cooney JP. What determines the start of prenatal care? Medical Care 23:986-997 1985. 17. Johnson CD and Mayer JP. Texas OB Survey: Determining the Need for Maternity Services in Texas. College Station, Tex.: Public Policy Resources Laboratory, 1987.

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BARRJERS TO THE USE OF PRENATAL CARE 83 18. Pamuk ER, Horn MC, and Pratt WE. Determinants of prenatal care utilization: Data from the 1982 National Survey of Family Growth. Paper presented at the American Public Health Association annual meeting, New Orleans, 1987. 19. See, for example, McDonald TP and Cobrun AF. The Impact of Variations in AFDC and Medicaid Eligibility on Prenatal Care Utilization. Portland: Health Policy Unit, Human Services Development Institute, University of Southern Maine, 1986. 20. Fingerhut LA, Makuc D, and Kleinman JC. Delayed prenatal care and place of first visit: Differences by health insurance and education. Fam. Plan. Perspect. 19:212-214, 1987. 21. O'Connell J. The Association Between Lack of Transportation and Lack of Child Care and the Adequacy of Prenatal Care. Providence: Rhode Island Department of Health, 1987. 22. U.S. General Accounting Office. Prenatal Care: Medicaid Recipients and Unin- sured Women Obtain Insufficient Care. Pub. No. GAO/HRD-87-137. Washing- ton, D.C.: Government Printing Office, 1987. 23. Hill I. Reaching Women Who Need Prenatal Care: Strategies for Improving State Perinatal Programs. Washington, D.C.: National Governors' Association, Center for Policy Research, 1988, p. 8. 24. Freedman SA, Klepper BR, Duncan RP, and Bell SP. Coverage of the uninsured and underinsured: A proposal for school enrollment-based family health insur- ance. N. Engl. I. Med. 18:843-847, 1988, p. 844. 25. Rosenbaum S. Hughes DC, end Johnson D. Maternal and child health services for medically indigent children and pregnant women. Med. Care 26:315-332, 1988, p. 315. 26. Ian Hill, National Governors' Association. Personal communication, 1988. 27. American Hospital Association. Medicaid Options: State Opportunities and Strategies for Expanding Eligibility. Chicago, 1987. 28. National Center for Health Statistics. Health care coverage by sociodemographic and health characteristics, United States. Prepared by Ries P. Vital and Health Statistics, Series 10, No. 162. DHHS Pub. No. (PHS)87-1590. Washington, D.C.: U.S. Public Health Service, 1987. 29. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 43. 30. U.S. General Accounting Office. Op. cit., p. 38. 30a.Rosenbaum S. Hughes DC, and Johnson D. Op. cit. 31. U.S. Bureau of the Census. Statistical Abstract of the United States, 1987. Washington, D.C.: Government Printing Office, 1986, pp. 371~12; and Chollet D.Op.cit.,p.18. 32. Alan Guttmacher Institute. The Financing of Maternity Care. Op. cit., tables 17 and 20. 33. ibid. 34. Kovar MG and Klerman LV. Who pays for prenatal care? Data from the National Medical Care Expenditure Survey, 1980. Paper delivered at the American Public Health Association annual meeting, Anaheim, California, 1984. 35. Sokol RI, Woolf RB, Rosen MG, and Weingarden K. Risk, antepartum care and outcome: Impact of a Matemity and Infant Care project. Obstet. Gynecol. 56:15~156, 1980. 36. Public Health Foundation. Unpublished data, 1987. 37. Bureau of Health Care Delivery and Assistance, U.S. Department of Health and Human Services. Unpublished data, 1988.

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84 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS 38. Brooks EF and Miller CA. Recent changes in selected local health departments: Implications for their capacity to guarantee basic medical services. Am. J. Prevent. Med. 3:134-141, 1987. 39. Rogers T. Rhodes K, and Silberman I. Report by the Prenatal Appointment Backlog Task Force. Los Angeles: Programs Division, Department of Health Services, City of Los Angeles Health Department, 1987. 40. Demand for prenatal care bogs down public clinics. Los Angeles Times. Novem- ber 8, 1987. 41. U.S. General Accounting Office. Op. cit., p. 41. 42. Southern California Child Health Network and the Children's Research Institute of California. Back to Basics: Improving the Health of California's Next Genera- tion. Santa Monica, 1987, pp. 79-80. 43. Kalmuss D, Darabi KF, Lopez I, Caro FG, Marshall E, and Carter A. Barriers to Prenatal Care: An Examination of Use of Prenatal Care Among Low-Income Women in New York City. New York: Community Service Society, 1987. 44. Johnson C. Current Perspectives on Prenatal Care. Lansing, Mich.: University Associates, 1984. 45. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Securing Access to Health Care, Vol. 1. Washington, D.C.: Government Printing Office, 1981, p. 81. 46. Southern California Child Health Network and the Children's Research Institute of California. Op. cit., p. 88. 17. American College of Obstetricians and Gynecologists. Unpublished data, 1987. 48. Dorn S and Dallek G. Medi-Cal Maternity Care and A.B. 3021: Crisis and Opportunity. Los Angeles: National Health Law Program, 1986. 49. Mitchell IB and Schurmann R. Access to private obstetrics/gynecology services under Medicaid. Med. Care 22:1026-1037, 1984. 50. Orr MT and Forrest]D. The availability of reproductive health services from U.S. private physicians. Fam. Plan. Perspect. 17:63-69, 1985. 51. Lewis-Idema D. Provider participation in public programs for pregnant women and children. Washington, D.C.: National Governor's Association, 1988, p. 3. 52. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 34. 53. Committee to Study the Prevention of Low Birthweight. Preventing Low Birth- weight. Washington, D.C.: National Academy Press, 1985, pp. 160-161. 54. American College of Obstetricians and Gynecologists. Professional Liability Insurance and Its Effects: Report of a Survey of ACOG's Membership. Washing- ton, D.C., 1983. SS. American College of Obstetricians and Gynecologists. Survey of Professional Liability and Its Effects: Report of a 1987 Survey of ACOG's Membership. Washington, D.C., 1988. 56. American Academy of Family Physicians. Professional Liability Study. Kansas City, Mo., 1986. 57. Lewis-Idema. Op. cit., pp. 21-25. 58. Oregon Medical Association. The Impact of Malpractice Issues on Patient Care: Declining Availability of Obstetrical Services in Oregon. Portland, 1987, p. 1. 59. Ibid., p. 3. 60. See the commissioned paper by Rosenbaum and Hughes at the end of this report. 61. National Association of Community Health Centers. Medical malpractice: Here we go again. Washington, D.C.: NACH newsletter. Winter 1986.

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BARRIERS TO THE USE OF PRENATAL CARE 85 62. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia. Personal communication, 1987. 63. Lewis-Idema. Op. cit., p. 25. 64. Southern Regional Task Force on Infant Mortality, Southern Governors' Associ- ation. Unpublished data, 1985. O , -I 65. Professional Management Associates, Inc. Improving MCH/WIC Coordination Final Report and Guide to Good Practices. Report submitted to the Office of the Assistant Secretary of Planning and Evaluation, Department of Health and Human Services. Contract No. HHS-100-84-0069. Washington, D.C., 1986. 66. Christison-Lagay J and Crabtree BE. Barriers Affecting Entry into Prenatal Care: A Study of Adolescents Under 18 in Hartford, Connecticut. Hartford: City of Hartford Health Department, 1984. 67. Toomey BG. Factors Related to Early Entry into Prenatal Care: A Replication. Columbus: Bureau of Maternal and Child Health, Ohio Department of Health, 1985. 68. See, for example, Learner M, Stephens T. Sears AH, and Efirt C. Prenatal Care in South Carolina: Results from the Prenatal Care Survey. Columbia: Department of Health and Environmental Control, 1987. With regard to usual source of care and pediatrics, see Kasper ID. The importance of type of usual source of care for children's physician access and expenditures. Med. Care 25:38~398, 1987. 69. National Govemor's Association. Selected State Medicaid Survey. Washington, D.C., 1986. 70. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 32. 71. Alan Guttmacher Institute. The Financing of Maternity Care. Op. cit., pp. 169-170. 72. Ian Hill, National Governors' Association. Personal communication, 1988. 73. Ibid. 74. U.S. General Accounting Office. Op. cit. See also American College of Obstetri- cians and Gynecologists. Health Care for Mothers and Infants in Rural and Isolated Areas. Washington, D.C., 1978. See also O'Connell J. Op. cit. 75. U.S. General Accounting Office. Op. cit., p. 40. 76. American Nurses' Association. Access to Prenatal Care: Key to Preventing Low Birthweight. Kansas City, Mo., 1987, pp. 27-28. 77. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia. Personal communication, 1987. 78. Dana Hughes, Children's Defense Fund. Personal communication, 1988. 79. Select Panel for the Promotion of Child Health. Better Health for Our Children: A National Strategy, Vol. 1. DHHS Pub. No. (PHS)79-55071. Washington, D.C.: Government Printing Office, 1981. 80. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia. Personal communication, 1987. 81. Peterson P. A Time Flow Study: Hutzel Prenatal Clinic. Detroit: Wayne State University, 1987. 82. Research and Special Projects Unit. Pregnant Women and Newborn Infants in California: A Deepening Crisis in Health Care. Summary of Hearings held March-April, 1981. Sacramento: California State Department of Consumer Affairs, 1982. 83. Kalmuss D et al. Op. cit., p. 47. 84. Ross CE and Duff RS. Returning to the doctor: The effect of client characteristics, type of practice, and experience with care. J. Health Soc. Behav. 23:119-131, 1982.

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86 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS 85. Poland M, Ager IW, and Olson IM. Correlates of prenatal care. Paper presented at the American Public Health Associates annual meeting, Las Vegas, 1986, p. 9. 86. See, for example, Juarez Associates. How to Reach Black and Mexican-American Women. Report submitted to the Public Health Service, Department of Health and Human Services. Contract No. 282-81-0082. Washington, D.C., 1982. See also Wan TH. The differential use of health services: A minority perspective. Urban Health 2:47-49, 1977. 87. Kalmuss D et al. Op. cit., p. 48. 88. Failer H. Perinatal needs among immigrant women. Pub. Health Rep. 100(May-June):340-343, 1985. 89. Kalmuss D et al. Op. cit., p. 47. 90. Chavez LR, Cornelius WA, and Jones OW. Utilization of health services by Mexican immigrant women in San Diego. Women's Health 11:~20, 1986. 91. Johnson CD and Mayer JP. Op. cit. 92. Klein L. Nonregistered obstetric patients: A report of 978 patients. Am. I. Obstet. Gynecol. 110:795-802, 1971. 93. See, for example, Brown MA. Social support during pregnancy: A unidimensional or multidimensional construct? Nurs. Res. 35:4-9, 1986. See also Kleinman IC, Machlin SR, Cooke MA, and Kessel SS. The relationship between delay in seeking prenatal care and the wontedness of the child. Paper presented at the American Public Association annual meeting, Anaheim, California, 1984. Chapter 3 contains additional discussion of this topic. 93a.Jones EF, Forrest ID, Henshaw SK, Silverman I, and Torres A. Unintended pregnancy, contraceptive practice and family planning services in developed countries. Fam. Plan. Perspect. 20:5~67, 1988, p. 55. 94. Poland ML and Giblin PT. Personal barriers to the utilization of prenatal care. Paper prepared for the Committee to Study Outreach for Prenatal Care. Institute of Medicine, Washington, D.C., 1987. 95. Toomey BG. Op. cit. 96. Bowling IM and Riley P. Access to Prenatal Care in North Carolina. Raleigh: North Carolina State Center for Health Statistics, 1987. 97. Oxford L, Schinfeld SG, Elkins TE, and Ryan GM. Deterrents to early prenatal care. J. Tenn. Med. Assoc. November:691~95, 1985. 98. Cumbey DA. Improved Child Health Project. Columbia, S.C.: Bureau of Maternal and Child Heald~, Department of Health and Environmental Control, 1979. 99. Johnson CD and Mayer JP. Op. cit. 100. Warrick L. A model for examining barriers to prenatal care and implications for outreach strategies. Paper presented at the American Public Health Association annual meeting, New Orleans, 1987. 101. Poland ML, Ager JW, and Olson IM. Barriers to receiving adequate prenatal care. Am. J. Obstet. Gynecol. 157:297-303, 1987. 102. Warrick L. Op. cit. 103. Poland ML. Ethical issues in the delivery of quality care to pregnant women. In New Approaches to Human Reproduction, Social and Ethical Dimensions, Whiteford L and Poland ML, eds. Boulder, Colo.: Westview Press, in press. 104. Chao S. Imaizumi S. Gorman S. and Lowenstein R. Reasons for absence of prenatal care and its consequences. New York: Department of Obstetrics and Gynecology, Harlem Hospital Center, 1984. 105. Boone M. Social and cultural factors in the etiology of low birthweight among disadvantaged blacks. Soc. Sci. Med. 20:1001-1011, 1985, p. 1008.

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BARRIERS TO THE USE OF PRENATAL CARE 87 106. Knoll K. Barriers and motivators for prenatal care in Minneapolis. Minneapolis: Minnesota Department of Health, 1986, p. IS. 107. Children's Defense Fund. Unpublished data, 1985. 108. American Medical Association. Medical care for indigent and culturally displaced obstetrical patients and their newborns. I. Am. Med. Assoc. 245:1159-1160, 1981. 109. Scrimshaw SCM, Engle PM, and Horsley K. Use of prenatal services by women of Mexican origin and descent in Los Angeles. Los Angeles: University of California at Los Angeles, 1985. 110. Research and Special Projects Unit. Op. cit., p. S1. 111. Chao S et al. Op. cit. 112. Poland ML et al. Op. cit. 113. Drugs get choke hold in early stages of life. Washington Post, January 17, 1988. 114. Margaret Haegarty, Harlem Hospital Center. Personal communication, 1988. 115. Chavkin W. Kristal A, Seabron C, and Guigli P. The reproductive experience of women living in hotels for the homeless in New York City. N.Y. State ]. Med. January:1~13, 1987. 116. Boone M. Op. cit. 117. Poland ML et al. Op. cit. 118. Giblin PT, Poland M, and Sachs B. Pregnant adolescents' health information needs: Implications for health education and health seeking. I. Adol. Health Care 7:168-172, 1986. 119. Johnson S. Gibbs E, Kogan M, Knapp C, and Hansen.JH. Massachusetts Prenatal Care Survey: Factors Related to Prenatal Care Utilization. Boston: SPRANS Prenatal Care Project, Massachusetts Department of Public Health, 1988. 120. Cumbey DA. Op. cit. 121. Cogswell BE and Fellow C. Adolescents' perspectives on the health care system: A determinant of fertility. Report submitted to the National Institute of Child Health and Human Development. Contract No. 1-HDE28737. Bethesda, Md., 1982. 122. Furstenberg, Jr. FF. The social consequences of teenage parenthood. Fam. Plan. Perspect. 8:148-164, 1976. 123. Cogswell BE and Fellow C. Op. cit.