National Academies Press: OpenBook

Prenatal Care: Reaching Mothers, Reaching Infants (1988)

Chapter: 2. Barriers to the Use of Prenatal Care

« Previous: 1. Who Obtains Insufficient Prenatal Care?
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 54
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 55
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 56
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 57
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 58
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 59
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 60
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 61
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 62
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 63
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 64
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 65
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 66
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 67
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 68
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 69
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 70
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 71
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 72
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 73
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 74
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 75
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 76
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 77
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 78
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 79
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 80
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 81
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 82
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 83
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 84
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 85
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 86
Suggested Citation:"2. Barriers to the Use of Prenatal Care." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
×
Page 87

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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 years—is 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

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

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

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 (AFDC—that 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

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

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.

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

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,

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

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 settings—stems 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

BARRIERS TO THE USE OF PRENATAL CARE 65 as housing, welfare, and nutrition. Organized settings are usually able to link women to a broader array of services than office-based private physicians are, and clinics often provide more comprehensive care, including, for example, classes in preparation for childbirth and parenting. Finally, some data indicate that pregnant women in these settings begin prenatal care earlier and receive more visits than comparable groups of pregnant women using other systems of care.35 Several data sources suggest that there is a growing demand for prenatal services in clinics a picture consistent with the increasing number of women of reproductive age without adequate private health insurance and the decreasing number of private providers caring for Medicaid-enrolled and other low-income women (see below). The Public Health Foundation, for example, reports that reliance on public health clinics for prenatal care has been increasing. State Health Agencies provided clinical services to 12 percent of pregnant women in fiscal year (FY) 1981, 13 percent in FY 1983, and nearly IS percent in FY 1985. The percentage of women receiving prenatal care in local public health agencies is probably higher because of underreporting to the state department of health.36 Community Health Centers (CHCs) and Migrant Health Centers (MHCs) have also emerged as major sources of care for poor families. Some S.S million persons obtain health care through these centers and prenatal services are an important part of the comprehensive services provided. The Bureau of Health Care Delivery and Assistance estimates that in 1986 the CHC-MHC network provided prenatal care to more than 118,000 women. The demand for perinatal services (both prenatal and delivery care) through these clinics has increased steadily during the 1980s.37 Hospital clinics are another important source of prenatal services, especially for women with high-risk pregnancies. In some urban neigh- borhoods, hospital clinics are virtually the only source. Although national data on the number of such hospital services and on trends in patient load are unavailable, numerous anecdotes suggest that in some communities demand for care in these clinics has increased dramatically in recent years. Are there enough of these clinics and enough appointment slots in each to care promptly for the women who seek services in these settings? Reports from several sources suggest that the answer is no. For example: a. Brooks and Miller compared information obtained in 1978-1979 and in 1982-1983 from IS local health departments geographically dispersed throughout the United States. In part because of reduced federal funding and a deep recession in the 4 years between studies, the departments as a group had smaller budgets and stags, experienced a greater demand for their services, and were forced to accentuate income-producing services.

66 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS Most of the IS reported reduction or elimination of maternity services, nutrition services, or both.38 b. In September 1985, the Los Angeles County Department of Health Services surveyed its 42 public health clinics and comprehensive health centers offering prenatal care. Twenty-five of these clinics had waiting times of more than 2 weeks for an initial prenatal appointment; the median waiting time in these 25 clinics was 21 days, and 16 had waiting times ranging from 4 to 14 weeks.39 As one of the authors of this backlog study saicl, "A woman has to call for an appointment before she gets pregnant to get an appointment before the end of her first trimester."~° c. In a national survey of barriers to prenatal care, the General Accounting Office cited numerous instances of limited capacity. For example, "according to the nurse coordinator at the Charleston tWest Virginial prenatal care clinic, the clinic has had to close admissions once a year for the past 4 years because of high patient volume and limited staff. Clinic personnel in mid-November 1986 . . . said that they would accept no new patients until mid-lanuary, 1987.' d. In a recent 3-month period ~ June through August 1986) in San Diego County, 1,24S women seeking prenatal care were turned away by publicly financed community clinics because the clinics were filled to capacity. Similarly, in Orange County, California, 2,000 women who turned to the county's prenatal clinics in 198S could not get appointments. County health officials estimated that half of the patients who could not be cared for at county clinics were unable to obtain prenatal care elsewhere in the county.42 e. A survey in 1982 of 12 private, nonprofit hospitals in New York City revealed waiting times for a first prenatal appointment of up to four months.43 In the absence of comprehensive state or national data, it is impossible to determine how widespread! such system overload is or whether other care networks have been able to meet changing needs. Numerous reports suggest, however, that in some communities the capacity of the clinic systems relied on by low-income women is so limited that prompt care is not always available and that in some additional areas care is unavailable altogether. It is important to stress that adequate, even excess, capacity can exist for affluent women in the same geographic area as inadequate capacity for low-income women. Maternity Care Providers Capacity also hinges on the distribution and practice patterns of providers. Obviously, maldistribution of physicians can affect a woman's ability to secure adequate, timely prenatal care. While there are more physicians per capita in the United States than in virtually any other

BARRIERS TO THE USE OF PRENATAL CARE 67 country, some communities do not have enough physicians to meet their needs and others have no physicians at all. In New York State, for example, there are 220 physicians per 100,000 persons, compared with only 80 per 100,000 in Mississippi; the national average is 140 per 100,000. More than S,000 communities, most of them rural, have no doctor.44 The uneven distribution of providers is a particularly serious problem in maternity care. In 1983, the state of Mississippi reported to the President's Commission on Ethical Problems in Medicine that S1 of its 82 counties had no obstetrician.45 Similarly, 11 of California's 58 counties have no board- certified obstetrician-gynecologist, and 9 of these counties have no public prenatal care clinic either.46 The American College of Obstetricians and Gynecologists reports that, although the number of residents and practicing obstetricians per 100,000 persons has been increasing, one-fourth of 577 areas in the United States (defined by zip codes) have fewer than four obstetricians per 100,000, and 38 of the 577 areas have no obstetrician at all.47 Even in communities with an adequate supply of providers, poor and uninsured pregnant women may not have access to care unless providers are willing to accept their form of payment. Large numbers of obstetricians in particular do not accept Medicaid as payment, and many more will not take patients who are uninsured. For example, a 1985 California survey found that 15 of the state's 58 counties had no obstetrician who would accept Medi-Cal patients—even though more than 13,000 women of childbearing age who were eligible for Medi-Cal lived in those counties.48 Among primary care physicians, obstetricians have been tagged as the least likely to accept Medicaid patients. Mitchell and Schurmann reported that between 1977 and 1980, nearly 36 percent of all obstetricians said they did not provide care to Medicaid patients, compared with 25 percent of general practitioners, 23 percent of pediatricians, and 20 percent of physicians in internal medicine.49 A 1983 national survey of private physicians who provide obstetric care found that 44 percent did not accept Medicaid reimbursement.50 Moreover, there is evidence that overall provider participation in Medicaid (including providers of obstetric care) has decreased in recent years.5i Several reasons have been cited for the limited and declining participa- tion in Medicaid of obstetricians and other maternity care providers: inefficient processing of Medicaid claims and burdensome paper work leading to delays in reimbursement; payment through a global fee rather than a per-visit fee; and a feeling that the risk of malpractice claims in a Medicaid population is greater than in other populations. The most important deterrents, however, appear to be rising malpractice costs (discussed below) and reimbursement rates that represent only a fraction of cost or of privately reimbursed fees. With regard to reimbursement, the Alan Guttmacher Institute found in 1986 that physicians' usual charges averaged $830 for a vaginal delivery

68 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS and $1,040 for a cesarean section; both figures included prenatal care. Medicaid reimbursement for these services was substantially lower. For example, although the maximum reimbursement for a normal vaginal delivery averaged $SS4, the range among states was substantial from $216 in New Hampshire to $1,027 inMassachusetts.52 Although Medicaid reimbursement rates have risen in recent years—quite substantially in a few states—they remain below physicians' usual charges. The problem of low Medicaicl reimbursement is exacerbated by the high proportion of Medicaid women who are high-risk patients. Because of multiple health and social problems, these women often need more frequent and comprehensive maternity care than more affluent women, and such extra care can be time-consuming and expensive to provide. Indeed, the case could be made that, because many pregnant women enrolled in Medicaid are at high risk, reimbursement for their care should be greater than average fees. The availability of nurse-practitioners and certified nurse-midwives (CNMs) deserves special comment in this discussion of system capacity. Despite the evidence that such personnel are particularly effective in manag- ing the care of pregnant women who are at high risk because of social and economic factors—and that CNMs especially serve disproportionate numbers of women who are poor, adolescent, members of minority groups, and residents of inner cities or rural areas—legal restrictions and obstetrical customs limit their numbers and scope of practice.53 At present, only about 2,600 CNMs are actively in practice in the United States, even though in many European nations they provide the majority of maternity services. Malpractice Underlying this complicated issue of a limited pool of providers is the current malpractice situation. In recent years, obstetrical providers' med- ical malpractice insurance costs have risen dramatically doubling be- tween 1982 and 1985 because of changes in medical technology, the use of national rather than local standards of care in assessing malpractice, questions of inadequate supervision and sanction of substandard physi- cians, large awards in malpractice suits, contingency fees for attorneys, certain insurance company practices, and other factors. These issues and others related to malpractice are discussed in more detail in the paper by Rosenbaum and Hughes, which appears at the end of this volume. The increase in malpractice insurance premiums and a growing concern about the risk of malpractice litigation are associated with the increasing number of providers who have discontinued or significantly reduced their obstetrical practice. A comparison of 1983 and 1987 surveys of obstetri- cian-gynecologists reveals that the percentage of respondents indicating decreases in their level of high-risk obstetrical care due specifically to

BARRIERS TO THE USE OF PRENATAL CAM 69 malpractice concerns increased from 18 percent to 27 percent. Malpractice concerns were also linked to a decrease in the number of deliveries that respondents performed and to an increase in the percentage who stopped practicing obstetrics altogether.5455 Similarly, in 1986 the American Academy of Family Physicians reported that 23 percent of its members had stopped practicing obstetrics due to malpractice concerns.56 Reports from individual states mirror these national trends." For example, an Oregon survey of physicians providing obstetrical services concluded in 1987 that"the availability of obstetrical care in Oregon has become a critical issue over the past few years as increasing numbers of physicians eschew the practice of obstetrics in light of increasing malprac- tice insurance premiums and a rising probability of litigation."58 Between 1984 and 1987, 25 percent of the pool of delivery physicians was lost in that state.59 Community Health Center directors in Florida, Texas, California, and New York report that local obstetricians who used to take referrals from CHCs no longer do so because they have given up obstetrical practice, largely in response to rising insurance costs and concerns about malpractice litigation.60 In some U.S. communities, particularly those with poorer populations and no teaching or public facilities, obstetrical care may be disappearing entirely. A closely related effect of the malpractice situation is that publicly financed clinics and health centers are finding it more difficult to obtain liability insurance and to find providers willing to serve in the clinics, thus contributing further to the reduced availability of subsidized maternity care for poor and uninsured women. Such chronically underfunded facilities as inner-city health centers often cannot afford increasingly costly insurance and must therefore cut back on their obstetric services. CHCs' insurance rates have risen so sharply that some centers have been forced to discontinue obstetric care entirely. Policies that cost between $800 and $900 in 198S cost $12,000 in 1986.6i Various communities, such as the District of Columbia, report that maintaining prenatal services in public clinics is becoming increasingly difficult because of liability costs and concerns.62 Confirming these scattered reports, 85 percent of agencies responding to a national survey on reasons for poor provider participation in public programs serving {ow-income women said that "physicians 'often' say they do not participate because public program fees are insufficient to cover their malpractice finsurance] costs."63 _ C7 ORGANIZATION, PRACTICES, AND ATMOSPHERE OF PRENATAL SERVICES Although the insurance and capacity problems described in the preced- ing sections are common barriers to prenatal care, use can also be limited

70 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS by the way services are organized and provided at the local level. Such problems usually cannot be resolved by giving pregnant women insurance or locating a provider. They stem from inadequate coordination among services, problems in securing Medicaid coverage, and such classic access problems as transportation difficulties, inhospitable provider practices, and cultural barriers. Although many of these problems are experienced primarily by low-income women they are not limited to the poor. Child care problems, for example, or difficulty in taking time off from work for a prenatal visit, can be experienced by women of all incomes. Links Among Services Several federal programs furnish prenatal care and related services to low-income women: Medicaid; the Maternal and Child Health (MCH) Services Block Grant; the Special Supplemental Food Program for Women, Infants, and Children (WIC); Community Health Centers; and Migrant and Rural Health Centers. Each is designed to serve a different function: a source of payment (MedicaicI), direct services (MCH Block Grant and health centers), and nutritional supplementation and education (WIC). In theory, these programs can furnish many pregnant women with a wide array of maternity services; in fact, however, the programs are not always carefully coordinated at the local level to ensure optimal benefits. More- over, links among these publicly financed services, private physicians, and such other service systems as welfare and housing are often fragile to nonexistent. Without doubt, limited funding of these programs has contributed greatly to their inability to ensure full access to comprehensive care. For example, the Southern Regional Task Force on Infant Mortality reported that, although Congress appropriated $457 million for the MCH Block Grant in BY 1986, all 19 states and territories surveyed by the Task Force claimed that Block Grant funds were insufficient to meet maternity needs.64 Even when fully funded, however, programs are difficult to coordinate because they are often independent of one another and have separate administering agencies, rules and guidelines, and organizational and political constraints. For example, although a woman may be eligible for both Medicaid and services through a health department clinic, enrolling in both systems may require applying at different sites, meeting different eligibility standards, completing different applications, and fur- nishing different documentation. Moreover, the programs may rely on different providers. In some states, public health clinics and CHCs are not certified as Medicaid providers, thereby limiting the choices available to pregnant women enrolled in Medicaid. Similarly, WIC services and prenatal care are not routinely coordinated. A Department of Health and Human Services study showed that, among

BARRIERS TO THE USE OF PRENATAL CARE 71 five sample states where income eligibility for prenatal services and the WIC program were identical, WIC enrollment among the prenatal care patients averaged only 58 percent. Such low rates of participation were attributed to many of the same barriers to coordination that exist between Medicaid and publicly financed prenatal services.65 Another important example of poor linkage is the gap between preg- nancy testing and prenatal care. Although pregnancy tests are widely available in a variety of settings, anecdotal reports suggest that a positive pregnancy test does not routinely lead to a prompt prenatal care appoint- ment for women who choose to carry the pregnancy to term. Pregnancy- testing sites commonly provide telephone numbers for prenatal services to women receptive to such a referral, but it is less common for a first prenatal visit to be actually scheduled or, if broken, followed up. This gap can be associated with major delays in beginning prenatal care. For example, a study in Hartford, Connecticut, showed that among teenagers under 18 there was a mean delay of almost S weeks between confirmation of pregnancy and a first prenatal visit.66 A study in Ohio found that, among a sample of {ow-income women, close to 40 percent waited 2 months or more after a positive pregnancy test to contact a prenatal care provider for an aDDointment.67 Ambivalence mav account for a significant amount of ~ ~ , ~ . . . . . . .. . . . ~ . .. this delay, but the studies also reveal an opportunity tor better coordina- tion among systems (see Appendix A). Whether a woman has a usual source of health care is another aspect of service coordination. Numerous studies have documented greater use of prenatal care among women who regularly use a health care facility than among those who, for example, rely on emergency rooms for episodic care or have no regular health care provider.68 Such studies suggest that women who have only a marginal connection to the health care system are not likely to establish one during pregnancy. Medicaid Application Procedures As described earlier, the Medicaid program is the major source of payment for care obtained by poor pregnant women, yet actual enrollment rates among eligible women are low and vary across states. A study by the National Governor's Association found that state enrollment among women who were newly eligible in the early 1980s ranged from 11 percent to 84 percent. For example, when North Carolina expanded its program to include several new groups of pregnant women, only 1,470 of an estimated 2,100 newly eligible recipients enrolled in the first year. Other states, including Arkansas, Texas, Mississippi, and Florida, report similar shortfalIs.69 Many problems and complexities in the administration of Medicaid underlie these gaps between potential and actual numbers of program

72 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS participants. In particular, Medicaid programs rarely invest in publicizing their benefits or how to enroll. Consequently, women may fail to obtain Medicaid coverage because they know little about the program, are unaware of their eligibility, do not know how to apply for coverage, or a combination of all three. For example, a recent survey of state Medicaid programs showed that brochures about the program rarely mention pregnancy as grounds for eligibility, and few conduct any comprehensive activities to let potential recipients know of the program.70 Given the relentless pressures on Medicaid to contain costs, the disinclination to advertise or to recruit recipients aggressively is not surprising. Even women who know about Medicaid and try to apply are not assured an easy process, particularly if they are not on welfare already (and thus automatically enrolled in Medicaid) and are eligible for the program only because of their pregnancy. Complicated application forms, a stressful certification procedure, denials of eligibility on the basis of incomplete evidence, requirements of extensive documentation, long delays between application and notification of eligibility, and loss of eligibility during pregnancy are widely reported. Many of these problems can be traced to state and federal regulations shaping the program and to the threat of fines for enrollment errors (in particular, enrolling women who are later found to be ineligible). Investigators from the Alan Guttmacher Institute found, for example, that applications run from 4 to 40 pages long, the average length being 14. They described how intricate the applications can be: A typical application often includes 80 or 100 questions about the applicant's and her household members' identity, income, assets and outgoings. There are usually ques- tions on the value of any property owned, jewelry, cars, life, health and burial insurance, cash on hand, Christmas fund accounts and many other items of value. Income from numerous sources is counted, including employment, public assistance, interest, scholarships, loans, gifts, free meals received, etc. The education and employment status of each household member is probed as are expenditures for such items as child care, utilities and medical bills. The identity of each household member must be proven by a social security card and/or a birth certificate and virtually every financial item must be documented. A single missing utility bill, apartment lease, rent receipt, or evidence of a checking account balance or child care expenses can cost an individual eligibility for the program. As one would expect, then, it can easily take applicants two or three visits—and sometimes more to the welfare or social service office to complete the application and supply the required documentation. Each visit can entail a half day at the office, much of it spent waiting to see an eligibility worker, and for some women may entail taking time off work without pay. Moreover, once an individual becomes eligible, any changes in income, expenditures or household composition must be promptly reported under penalty of losing benefits, and eligibility must be redetermined periodically, as required by the state. In most states, a Medicaid card is mailed to recipients monthly to minimize the chances of an ineligible person having use of the card. In the 6 states where Medicaid is administered at the county

BARRIERS TO THE USE OF NATAL CAM 73 rather than the state level, additional application forms and procedures may be required.7~ A lapse of several weeks between application for and notification of eligibility is common. States in the South, for example, report an interval of about S weeks. Moreover, if the actual Medicaid card is not sent with the letter notifying a woman she has been found eligible, additional delays in obtaining prenatal care may occur, because some health care providers are reluctant to accept the letter as evidence of enrollment. A recent provision in federal Medicaid law permits states to authorize certain health care providers to make preliminary determinations of Medicaid eligibility for pregnant women and to be reimbursed for providing services to them for 45 days or until eligibility is actually determined so-called presumptive eligibility. By July 1988, 19 states had adopted a presumptive eligibility program for pregnant women.72 Another option open to states that wish to shorten the application process is waiving consideration of assets in determining eligibility. As of June 1988, 2S jurisdictions had completely eliminated use of an assets test, and a few others have simplified and liberalized their means test. States have also recently been given the option of ensuring continuous, uninter- rupted coverage for Medicaid-enrolled pregnant women, eliminating the risk of losing coverage in the middle of pregnancy. As of June 1988, 27 jurisdictions had taken advantage of this provision.73 The di~cult application process, the complexity of the program and the great variations in the program across states create the impression of a system designed to discourage rather than encourage entry into prenatal care. Although Congress and the states have taken a number of steps recently to improve Medicaid- in particular, to broaden eligibility—the program is still limited in its ability to draw low-income women into prenatal care promptly with minimal bureaucratic harrassment. Classic Barriers to Access Several classic access barriers, well recognized in the large literature on barriers to health services generally, continue to limit prompt enrollment and continuation in prenatal care. These include problems with transpor- tation and child care, the practices and attitudes of some providers, language barriers, and cultural differences between patients and providers. Recent work by the GAO and others describes the transportation problems linked to insufficient use of prenatal care long distances to reach a provider, the high cost of transportation, and no transportation whatever.74 For example, in Bluefield, West Virginia, many women travel up to 2 hours for prenatal care, and in the Birmingham, Alabama, area, bus transportation is not available in many parts of the county served by the

74 PRENATAL CAM: ACHING MOTHER, ACHING INFECTS health department.75 Similarly, the American Nurses' Association describe a county health department that offers prenatal care and that is centrally located to serve an entire region- the county is without public transpor- ration, however, and women in adjoining counties traveling by bus can get only as far as the county line, which is IS miles from the clinic.76 When prenatal services are not coordinated with public transportation, additional problems can result. Staff at a large Washington, D.C., public hospital report that one reason women fait to keep early morning appointments is that the bus system in the neighborhoods where most patients live does not begin running by the time patients are expected to be at the clinic.77 These anecdotes suggest that transportation problems are closely asso- ciated with and may even be seen as a proxy measure of poverty, particularly the lack of a car and the resulting dependence on imperfect systems of public transportation. In rural areas, where distances to care can be great, the absence of a car can be an insurmountable obstacle. Medicaid programs are required to cover "medically necessary" trans- portation costs for enrolled individuals. However, few women know about the option and the process of securing reimbursement is cumbersome.78 For indigent women not enrolled in Medicaid, little help is avalable to meet transportation costs. The availability of child care can also affect use of prenatal care. If affordable, convenient child care is difficult to arrange, a pregnant mother may have to bring older children with her to a prenatal care appointment. If there are no child care services nearby or if waiting times for the visit are long, the burden of taking children may outweigh the perceived benefits of the prenatal visit. Studies that ask women about reasons for delayed or no prenatal care confirm that responsibility for other children can interfere with keeping appointments.79 Accessibility problems created by long distances to care, inadequate transportation, and lack of child care are compounded by limited clinic hours. Most prenatal services are offered during "normal" working hours (that is, weekdays from, 9:00 a.m. to TOO p.m.~. For women who work or go to school, the only time available for appointments is usually the lunch hour, when many clinics do not see patients. Even if appointments can be scheduled during the lunch hour, a woman's ability to make such a visit depends on her distance from the provider. If the distance is great and thus more than an hour is required to complete the visit women working for hourly wages must forego pay, those in salaried positions risk recrimination for taking too much time off, and those in school miss class time or must miss school altogether. Recently, the District of Columbia began offering prenatal services during evenings and weekends in order to accommodate work and school schedules; it was also recognized that child

BARRIERS TO THE USE OF PRENATAL CARE 75 care is often more easily arranged during evenings and weekends. Patient load increased dramatically at sites with the expanded hours. Although other reforms were also instituted simultaneously, program staff believe that the change in hours was the most important cause of the increased enrolIment.~° Long clinic waits can be a deterrent to seeking or remaining in prenatal care. In publicly financed clinics, service is often delayed routinely,8i partly because of block appointments. This system scheclules only two groups of appointments a day, one at 8:00 or 9:00 in the morning and another at 1:00 in the afternoon, with patients seen on a first-come, first-served basis. While the first patient who arrives may be seen promptly, the tenth patient may have a 2- or 3-hour wait. Clinics use such systems to make certain that physicians' time is not wasted and to avoid gaps in appointments when patients fait to appear. A wait of several hours can be frustrating and humiliating for the patient, however. Few people have the time—or the patience to wait long hours, and the costs (in lost wages or school time, extended childcare, and so on) can be burden- some.82 One study found that low-income women considered the long waiting times at clinics to indicate a disregard for the importance of their time; it was particularly insulting to have only a few minutes with a doctor after waiting several hours for the consultation.83 Another practice that influences enrollment in care is that of asking women to wait until at least two menstrual periods have been missed before scheduling a prenatal appointment. Though designed to provide prenatal care only to women whose pregnancies have progressed beyond the first few weeks when miscarriage often occurs, this policy obviously causes delays in onset of care for the majority of pregnant women who do not miscarry. Use of care can also be influenced by the attitudes and styles of providers, including poor communication about procedures, failure to answer questions, seeing a different provider at each visit, and hurried or otherwise depersonalized care. For example, in a study of determinants of remaining in care in a pediatric setting, Ross and Duff found that when a parent felt the doctor was a good listener, respectful, and willing to give and take, compliance was better than when the physician was seen as insensitive, unwilling to answer questions, and not respectful.84 Similarly, anecdotal information suggests that clinic "gatekeepers"—such as appointment clerks and receptionists—can discourage continuation in prenatal care by being rude or indifferent. As one woman said, "Getting prenatal care in a clinic is a real hassle, but that's what you have to expect when you're poor.'~5 The difficult relationship and failure of communication between health care providers and low-income clients have been described by many authors.86 Causes probably include the different socioeconomic and cultural backgrounds of the groups, the awkwardness and stigma often

76 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS attached to charity care, and cultural differences that affect beliefs about illness and health. Such differences can result in an unfortunate mix of hostility, passivity, and evasiveness on the part of the client, matched by arrogance, testiness, and indifference on the part of the provider. Language incompatibility exacerbates many barriers. Clinics located in relatively large communities of persons who speak a single, non-English language are likely to have interpreters, if not bilingual providers. How- ever, bilingual providers or medically trained interpreters are not found in most prenatal care settings. Even when children are brought along as interpreters a very common practice in some areas—communication remains inadequate. An anthropologist describing prenatal clinics for iow-income women in New York City noted, "In most of the clinics I visited there was only one interpreter available for every large non-English speaking population. Usually these interpreters were clinic staff members who worked full-time in another capacity. When interpreters were needed they were often not available because they were generally busy with other work."87 Experts cite the failure of providers to appreciate the cultural prefer- ences of some patients as an important barrier to care. Among some Hispanic and Asian populations, for example, it is unacceptable to have a pelvic examination done by a man. Yet not all clinics are able to accommo- date such preferences, because most physicians are men and not all settings can or will rely on certified nurse-midwives or nurse-practitioners. The physical surroundings of many prenatal clinics for low-income women~reary, usually very crowded, and uncomfortable form another barrier. A study of several New York City prenatal clinics noted that there are usually too few chairs in the waiting rooms, leaving patients to stand in corridors.89 Finally, lack of easily available, widely disseminated information about where exactly to go for prenatal services can be an obstacle to care. Studies report that 5 to 18 percent of patients who had obtained little or no care did not know where to seek services.9~92 Given the relatively poor accessibility of clinic telephone numbers, it is not surprising that this barrier can be significant. Few telephone books, for example, have a listing for "prenatal care" or a similar phrase. CUETURAE AND PERSONAE BARRIERS Previous sections have outlined potent barriers to care created by inadequate insurance, limiter! capacity in the prenatal care system, and the policies and atmosphere of prenatal clinics themselves. It is also apparent that the use of prenatal care is influenced by a woman's attitudes toward

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

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

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

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 present—positive 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

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 care—phone 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

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.

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.

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.

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.

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.

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.

Next: 3. Women's Perceptions of Barriers to Care »
Prenatal Care: Reaching Mothers, Reaching Infants Get This Book
×
Buy Paperback | $57.95
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Prenatal care programs have proven effective in improving birth outcomes and preventing low birthweight. Yet over one-fourth of all pregnant women in the United States do not begin prenatal care in the first 3 months of pregnancy, and for some groups—such as black teenagers—participation in prenatal care is declining. To find out why, the authors studied 30 prenatal care programs and analyzed surveys of mothers who did not seek prenatal care. This new book reports their findings and offers specific recommendations for improving the nation's maternity system and increasing the use of prenatal care programs.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!