Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 88
Chapter
3
Women's Perceptions of
Barriers to Care
The perspectives presented in the preceding two chapters are not new.
Many studies have already noted that the absence of private insurance, for
example, can impede prompt enrollment in prenatal care. Not as well
documented is the personal significance of various barriers to women
themselves. Few reports on obstacles to prenatal care cite "consumer"
views, and programs aimed at increasing participation in care are often
designed without careful consideration of women's experiences in obtain-
ing prenatal services.
To begin filling the gap, this chapter summarizes several studies that
have asked women to identify factors that limited their use of prenatal
services during pregnancy. The chapter also presents a brief section on
obstetricians' views about factors causing late registration in care. It
concludes with a synthesis of several studies that have used multivariate
analysis to define the characteristics (demographic, social, attitudinal, and
others) that predict insufficient prenatal care.
The Committee's interest in the consumer perspective was stimulated in
part by the experience of Lea County, New Mexico, where a survey of
clients concerning barriers to prenatal care helped shape a local initiative
to increase early enrollment (see Appendix A for more detail). In the early
1980s, a grant from The Robert Wood Johnson Foundation supported a
major effort in Lea County to reduce its infant mortality rate. Although the
area reported one of the highest per-capita incomes in the state, its infant
mortality rate was the highest among counties with over 1,000 births per
year, and use of prenatal services among some groups in the county was
88
OCR for page 89
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
89
very low. To determine what might account for the limited use of prenatal
care, a survey of women's views about barriers to care was initiated at the
request of several community physicians who felt that financial obstacles
were probably unimportant and that factors such as cultural practices and
lack of information were decisive. Four hundred mothers were inter-
viewed, of whom 92 had recently arrived in labor at the area's only hospital
having had little or no prenatal care. Contrary to physicians' expectations,
77 percent of these 92 women stated that they had not received prenatal
care because they believed they could not afford it.i This significant
difference between the perceptions of providers and clients helped stimu-
late eEective remedial action.
SEEECTION AND SYNTHESIS OF STUDIES
To learn more about women's views concerning barriers to prenatal
care, the Committee searched for studies of women who had obtained
insufficient prenatal services and who had been asked about factors they
felt had caused their delay in entering care. Only studies completed in the
last 10 years preferably in the last S years—were reviewed. Surveys with
fewer than 50 respondents were not included in the synthesis described
below but were considered nonetheless for possible additional perspec-
tives. The Committee was particularly interested in studies that surveyed
three groups of women: those who had obtained insufficient prenatal care;
those who had obtained no prenatal care at all; and adolescents, particu-
larly those 17 and under.
Seventeen studies that met these criteria were located;2-~8 a few of them
reported on two of the three groups. Fifteen presented data on barriers
reported by women with insufficient prenatal care; six presented data on
barriers cited by women who had obtained no prenatal care at all; and
three studies included a special analysis of the barriers cited by adoles-
cents. In the next three sections, each of these sets of studies is discussed.
Studies of Women with Insufficient Prenatal Care
Fifteen studies of women who had obtained insufficient care are
characterized in Table 3.1* along several dimensions: the year in which the
data were collected; whether the data were collected in the prenatal or
postpartum period; the number of women who responded with valid data;
*The sixteenth study listed on Table 3.1, from Hartford, is discussed in the section on
adolescents.
OCR for page 90
at
-
en
at
·o
In
3
·3
._
In
. -
o
.~
Liz
~ U.
_ ~ o
o I ~ ·
_
~ ~ O ~ O Y
.~ ~ '_
3 C ~ ~
4 - _
-
o
,_
In en
—
on
o
~ 3= =~
o ~ ~ o
~ =~^ o ~ ~ ~
~ PA ~ ~ ~ ~ ~
-
z
P"
Cal
4—
~ - o
a ~
~ _
~ O
0 0 cr 0
~ ~ ~ 00
- i ~ ret ~
O ~ ~ O
_
= ~ ~ .~=
3.
m in E =-
^-
~ C4
0
0 0
_ ~
._
3
0 0
_ _
.=
o ~ .~
~ ~ .= 3
m~ m^ =^
UN
0
-
~n
Cal
0
.^,.Q O
Its as z5
~n ~ O ~ In ~ O r~
0 UN ~ ~ O
o ~ ct ~ - 1 — — — ~ ~ —
Z
O ~ O ~ ~ ~ r~
r~ ~ ~ ~ ~ O
_ ~ _
~ _
— 1- ~ u ~, ~ O _ _
_ aJ ~ ~ ~ ~ ~ ~ 3 ~ ~ 3 ~ ~ ~ ~ ~ ~
_ ~ ~ ~ ~ E ~ ~ fi ~ ~ ~ D E ~ E
U~
~ o
0 0
0 ~
~n
o
-
~ :t :`
P-^ Z Z~
~o
· _
3
-
~ ~ I ~
0 0 oo 0
cn crN
- - - ~
m~ ~ ~ ~ ( _V~ ~ ~ ~ L~ J~ ~ =0 ~ O
OCR for page 91
91
In ~
Lie
o o o o o o ~
to ¢ ~ ~
n ~ ¢
~ ~ ~ ~ z
O ~ ~ rid rid ~ 04
¢
~ ~ ~ z
Id
.5
~ ~ ~ ~ ~ ~ _ ~~ ~ ~ E ~ ~ °
4, L4 =0 ~ ~ ·~- 0 ~ do A,: ~ <~; O .5 <~`
¢ ¢ ¢ (~~ ASH Go
_ ~ Go —
o o ~ UP Go
do — — UN Us
U)
o o
Us In ~ C ~
~ ~ _ _
._ ._ ._ o o
5: i=
.~ a a
3 3 3 :^
Z ~,,^ lo,- ~ lo, ~ Z
oo oo
CSS ~
_
-
3
z
~ U~ ~ ~ ~ ~
oo oo oo oo oo oo
~ C~
_ _ _ _ _ _
3
C~ ~
·^ X ~ IL, crs
e~ ~ ~ ~ ~ o
O ~ ~ ~ ~ =m O ~ ~
.
_ ~ ~ o ~ ' ~ o
o Z
a: _
~ ~ ~ 3
._ ~ _ ~
:e ,,, o .5
: ~ (,, ° o
·~=
U,
o <
o — o _
~ ,~ ~ ~ ~ ~
3 0, t43 o., ~ ~
.— ~ ~ ~ . - .—
O ~ ~ D ~3 ~
~ ~ ~ ~ o
~ ~ `:4 . ~ ~ 3
O ~ O c~s ~ ~ ~ D
~ <,, ~ ~ ~ 3 ~ ~
O ~ ~ O ~ O ~ ~
o ~ ~ ~ ~ ~ ~ C
~ ._ ~ ~ ~ o ~
3 ~ o ~ 5~3 3 ~ ~
C~ ~ ~ ~ ~ o ~ ~
B E ~ o E C B B
~ ~ ~G ~ == ~4 E, B ;,
~Zi- t~=
.= ~ ~
L.
OCR for page 92
92
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
the overall response rate; the study's definition of insufficient prenatal care;
the number of women with insufficient care who provided data regarding
barriers to care; and whether the information on barriers was obtained
through open-ended questioning or a self-administered checklist.
To synthesize the results of these studies, they were analyzed in two groups:
those that used a self-administered checklist (nine studies) and those that
used open-ended questions (six studies). First, the comparability of the nine
checklists was assessed. To help in this content analysis, 10 broad categories
were defined into which all of the individual checklist items could be fitted.
The eleventh category was for the few items that could not be otherwise
classified. Table 3.2 shows the items that were subsumed within each
category. The checklists were then analyzed again to determine which
categories were on each list. This step was necessary to avoid pooling results
from checklists that may have had nonequivalent contents. Finally, the top
four barriers cited by the women were identified for each survey.
Table 3.3 presents the results of analyzing the nine checklist studies. It
compares the lists' contents and notes the top four barriers reported by
each (see the footnotes to the table). As the table shows, all checklists
included items on financial obstacles to care and on transportation
problems. Eight of the nine included prenatal care being poorly valued,
some measure of inhospitable institutional practices, and a dislike or fear
of prenatal care. Many of the other five categories were also covered by a
majority of the nine surveys.
To summarize the six studies that used open-ended questions, responses
were assessed using the same 10 categories, and the four most frequently
cited barriers were noted. Because open-ended questions by definition do
not present respondents with a checklist or similar form to complete, the
process for analyzing content described above was not necessary. Table 3.4
presents the responses recorded in these six studies.
Both data sets (Tables 3.3 and 3.4) reveal that financial barriers—
particularly inadequate or nonexistent insurance and limited personal
funds- are the most important obstacles reported by women who received
insufficient care. Transportation emerged as a substantial barrier in the
checklist studies, although, as noted in Chapter 2, this barrier should
probably be viewed primarily as a proxy for general financial stress rather
than as a separate obstacle.
A very important message from both types of studies is that many
women who obtain insufficient care attach a low value to prenatal care.
This barrier was second only to financial problems in the open-ended
studies and was in third place in the checklist studies. Other barriers that
frequently appeared in both types of surveys among the top four include
some variation on "I didn't know I was pregnant," and inhospitable
institutional practices. The open-ended questions also reveal that limited
OCR for page 93
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
TABLE 3.2 Items Included in Each of the 11 Categories of Barriers to
Care Cited by Women with Insufficient Prenatal Carea
93
1. Financial
Not enough money
Couldn't afford it
No insurance
Insurance didn't cover prenatal care
Cost of the visit
Not eligible for Medicaid
Problems with Medicaid
Financial, not further specified
2. Transportation
Couldn't find a way to get to the appointment
No transportation
Transportation, not further specified
3. Prenatal care poorly valued or understood
Already knew I was pregnant, so no reason to go
Prenatal care is not necessary
It's not important to seek prenatal care early
I felt fine so there was no reason to come in earlier
Prenatal care is necessary only if you're feeling sick
I already knew what to do since I had been pregnant before
I had no problem in previous pregnancies, so I didn't need to come
Friends and relatives could answer my questions
Too busy
Too many other problems/things to do
No room in my schedule
4. Didn't know I was pregnant
I was not aware I was pregnant
I didn't realize I was pregnant for a long time
5. Negative institutional practices
Wait in office too long
Too much paper work involved
Clinic hours inconvenient
Could not miss work
Could not get time off from work
Language problems
No one spoke my language well enough
Location inconvenient
Continued
aThe wording of each item included under the 11 major headings is either that
used in an individual study or a synthesis of very similar items from several
studies.
OCR for page 94
94
TABLE 3.2 Continued
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
I didn't know where to go
I was new in town and didn't know where to go
I didn't know about the clinic
6. Ambivalent/fearful about being pregnant
I changed my mind about wanting an abortion
I didn't think about being pregnant
I was afraid to find out I was pregnant
I did not want others (parents, friends) to know I was pregnant
I didn't want to tell others I was pregnant
7. Limited provider availability
No doctors, nurses, or midwives in the area
My regular doctor did not provide prenatal care
I was turned away from the first place I tried to get care
No doctor would see me
The doctor/clinic was not taking new patients
Could not get an appointment at all
Could not get an appointment earlier
Couldn't find a doctor who took Medicaid patients
8. Child Care
No one to take care of my children (or other family members)
Problems arranging child care
Child care, not further specified
9. Disliked/scared of/dissatisfied with prenatal care/provider
Disliked or scared of doctors, medical tests and procedures
Previous poor experience with health clinics
Don't like the provider or provider's behavior
Never see the same doctor twice
Dissatisfied with prenatal care, not further specified
10. Other fears
I was afraid I'd be asked to have an abortion
I was afraid they would take my baby away
Immigration problems
I was afraid I'd be reported to the INS (Immigration and Naturalization Service)
I was afraid, not further specified
11. Other reasons
Family problems
My family didn't want me to go
Was not in the area until time of delivery
OCR for page 95
OCR for page 96
OCR for page 97
OCR for page 98
OCR for page 104
OCR for page 106
OCR for page 107
OCR for page 108
OCR for page 109
OCR for page 110
OCR for page 111
OCR for page 112
OCR for page 113
OCR for page 114
Representative terms from entire chapter:
insufficient prenatal
9s
-
c~
~ -
.—
-
.¢
.—
o
As
As
o
4 -
L.
·5-
Ed
Ad
o ·~
~ of
o ~
.m
-
At:
^
~ .5 ~
8 ~ ~ z
8 °
. ~ L4
.-
6.o
~ , ~
Cal
E
96
-
4 -
C~
sit
4=
._
cry
c
._
._
a
-
Cal
._
L4
Ct
~ o
o ~
~ O'
o ~
&
O
^
(J
~ en,
·~ o
i)
.~
s~=
A:
Z .=
._ · ~ _
— ~ o
3 ~ ~
o — Cal
Z ~
In .
—In
. ~
o ~
~ ._
Z ~ °
o
OX o
. ~
—
.v)
~4
o ~
ct ~
~ z ~
s~
. -
ct
O 0~= r~ ~ O O O ~ O r~
O u~ ~ r~ ~ u~ _
~ - ~ ~ ~
rn
~^
o
o
- ~ ~
.= ~ ~ ==
.=
L~
ct
t4-
_ ~ ~ ~ '
cz ¢
r~
o ,~
~n
"
(U
.m
~ oo
~4
~o
· - ~
o
c~
·
·
c~
o
4 -
o
c~
~n
·
·
~5
o
· -
~n
· -
rQ
40-
~:
~4
o
c~
c~
.
r
~n
c~
.
c~ -
~ o
· -
· -
- = - ~
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
97
provider availability and dislike or fear of prenatal care are important
obstacles. These data suggest that removing financial impediments to
care would be a highly appropriate response to the views of women
themselves, as would efforts to combat the opinion that prenatal care has
little or no value.
Studies of Women with No Prenatat Care
Six surveys ar~alyze`d barriers reported by women who obtained no
prenatal care at all, a group widely recognized as being at high risk for
numerous social and medical problems (see Table 3.S). These surveys are
characterized in the table by the same variables used to describe the
surveys of women with insufficient care. As before, the studies were
analyzed in two groups those that used checklists versus those that used
open-ended questions.
Again, financial barriers emerge as the most important obstacle (Table
3.6~. In five of the six surveys, financial problems were the most frequently
cited barrier. The second was a low valuation of prenatal care, a finding
which suggests that many women who have received no prenatal care are
particularly isolated from health services generally and may have only
limited appreciation or knowledge of their value. It is also consistent with
the view that these women live complicated, highly stressful lives charac-
terized by many daily problems and struggles (see quotation below). It is
perhaps not surprising that, for them, prenatal care is of low priority. Table
3.6 also reveals that other commonly reported barriers include transpor-
tation difficulties, inhospitable institutional practices, and a dislike or fear
of prenatal services.
These studies of women with no prenatal care at all are a rich source of
data and descriptive material. In their study of high-risk New York City
neighborhoods, for example, KaImuss et al. summarized a range of
demographic, behavioral, and attitudinal variables that distinguished
women who had received some prenatal care from those who had obtained
none. They found that:
. . . women who reported receiving no prenatal care during their pregnancies are more
likely to be disadvantaged socioeconomically [than a comparison group of women who
received at least some care;. They are more likely to be single mothers and to have left
high school before graduation. The no care women are behind other women
educationally. Only 35 percent of them had the appropriate number of years of
schooling for their age group, as compared to 60 percent of the total sample. Perhaps
because of poverty and low levels of education, the no care women at best were
peripherally connected with the health care system. They were significantly less likely
to have a regular health care provider, to have received prenatal care in a previous
pregnancy, or to be insured. The attitudes expressed by these women regarding health
98
— o ~ °
~ _% ~ _
o ° o' 1
o
°
~ ~ V
en
~4
z
I
en
o
._
L.
so
o
._
Lo
¢
o
C
~ —
C —
o :~% ~ =
U.
~ ~ ~ Cat Pi ~
_ -
z
~ - o
a ~
~ O
. O ~
~ ~ ·!!
~ 0 ~ 0 0 0 13.0 ~~
, o
_ _ ~ ~ 00
oo ~ ~ ~ ~ o3 ~=
~ ~ E 3
_ ~ ¢ ~ ~ ~ ~ ~ ~
I,, ° ~
X (~ ~ ~ ~ °
0 ~ In ~ ~ ~ ~
c i., ~ ~ E E j ~ 3 ,,
·, t- ~ , ° o ~ ~ ~ °
{,, ,3 {,, ~ ~ °
Cat
I 1
cs' ~ ~ ~ ~ ~ 3 ^= ~
~ ~ ~ ~ ~ S
: 8 ~ ~ ~ ==Z ~ ~ AS
104
Ct
Ct
4 -
o
In
o
C)
._
~4
o
In
en
._
._
4 -
.=
sit
o g ~
=~i
;^ e.
~ ~ ¢
~ ~ A_
o ~ ~
.° ~ ,~
. -
. - Cal o
._ ,~ OF
.m
Cal
o
,
en I ~
o
:- ~
~ C ~ - C ~
~ =~ o ~ ~ ~
o~ 'it
Cal ~ _-
~ ~ A
~ _
~ o
C~
° 0 _ ~ ,o ,o ,o
J o~ ~ 8 ~ ~° ~ ~,
oo ~ ° _ o o
(~1 r~ ~} ~ ~ _ ~ ~ O ~ ~v oo ~
^.~s (~ o t
OCR for page 105
105
c :,, a C c
O ~ ~
0 ~ - 0
of ~ oh. = - of
~ ~ 0 ~ ~ in- UN ~
¢.i ~ ~ ~ ~ of ~ ~ ~ ~
. == ~ g ~ ~ == ==
=3 Jazz ¢3 <3
E ~ o ~ E 9 E o ' ~ E ~ E 3, °
D ~ ~ .— O ~ ~ D ~ ·> ,C ~ ~ D ~ ~ C
~ ~ ~ O
O ~ _
Z rid _
rid O O
~ 0 Ch O
O ~ _ U.
~1 U. ~ _
_ ~ ~
V) O ~ ~ _
u, ~ ~ ~ 1 ~ °
~ ,~, 3 ~ ~ ° ~ $
-
oo a~ oo 0
c~ ~ a~ c~
_ _ _ _
_ ;`
Y ~ ~ E 3 o~ ~ ~ ON Y ~ E
cn ~ 3 ~
O ~n
s~
_
b° 1:5 ~ t\
(,., ° ~
·X
o
~ C
o ~ ~ ~,
~o .= =
C :, C
._ ~ ~ ._
3 ~ ~ .~
~ ~ ~ .m
._ ~ ~ V)
~n 0 ° :^
o .:> C~ .=
~ ~ ~,
C~ ~ ~ e~
~ ~ ~ ·z
=: " ~ C
o o ~ ~
C ~ (.s C
,- ~ <'s ~
0 U)
_ ~ 0
Ct -= =
"s:
_ b4 ~ ~
~ 3 ~ o ~
_
~s . ~ o
~o
<5 C,) ~ ~ ~ V)
~ ~ C~ o ~
~ .5 =, ~ ~ . v,
C
o
C C
._
106
Cat
._
-
o ~
~ ¢
.=
a to
-
4 -
o
.q) _
~ ~0
.... —.
"D ~ ~ ~ =~
in
V)
~ ~ ~ O ~ PI
~ ~ _
a ~~
~ ~ if
:S
lo
a ~
_
as - o
O O O O _ ~ —
._ ,,, ~ ~ O
~ ~ ~ ~ V,
4- OF i/) On or, on ark to
C~ ~ ~ ~ ~ _.
~ S~ ~ ~ ~ ~ ~ L4 ~0
_ ~ — ~ ~ ~ ~ ~n ~ ~ ~ O
~S ct ce c~ e~s ~ O5 c~S ·— ~ _
O O O O ~i o~ .
i
m
Ct
¢ ¢ ¢ ¢ S~ ~ ~ C~
Z Z Z Z <:
' ~ ~ ~ ~ ~ ~ ~b ~ ~
oo oo c4 o,,l o
cs ,~, ~~ cx~ 3
oo _ ~ ~ ~ u,
oo ~ ~ :-
- ~ oo ~ ~ ~
00 ~ ~ r~ C~ ~ ~ ~ Ch
_
_ _ ~ 0 ~ ~ .= ~0
S~ ~ L4
_ c~
_l ~ ~ ~ ~ ~ °
.° ~
c~ Z,=
~ ~ ~ ~ ~ ~ =,=~_
oo oo oo oo co 0 ~ I., (
cr ~ ~ c~ ~ 0 ~ ,=
_ t_ ~_
=~ c == ~ `,, ~ E ~ ~ -
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
107
constructed unique scales to measure various factors thought to predict
use of prenatal services (for example, scales of attitudes toward health care
and of personal and family stress), which also makes it difficult to
synthesize findings.
The items found by each study to predict insufficient prenatal care are
presented in Table 3.8; the wording and specificity of the items have been
simplified for comprehensibility. Where available, odds ratios are pre-
sented, as is the amount of variance accounted for by the items listed
(r2 value). Only items statistically significant at p ' .0S are presented.
Even without pooled results, several themes are clear. First, a striking
number of studies found various markers of poverty (especially inadequate
or nonexistent insurance) to be significant in predicting insufficient care.
The fact that the presence of Medicaid is also frequently found to be
predictive of insufficient prenatal care underscores an important theme in
Chapter 2: that although having Medicaid is undoubtedly better than
having no insurance at all for the very poor women covered, the program
has clearly been unable to draw low-income women into care efficiently
and early in pregnancy.
Second, among most of the studies, minority status was notably absent
among the factors found to predict insufficient prenatal care. This suggests
that it is the concentration of other risk factors among minority groups
poverty and less education, for example—that accounts for the low level of
care.
Third, the significance of unintended pregnancy emerges in many of the
studies. Various descriptions of this concept appear in the analyses
unwanted, unplanned, mistimed along with such markers as delay in
telling others of the pregnancy and long intervals until the woman
suspected or knew she was pregnant. Although these terms and markers
are different in precise meaning, it is possible to distill an overall theme:
Women who clearly planned their pregnancies and who therefore antici-
pated and promptly detected the early signs of pregnancy were more likely
to secure adequate prenatal care than women who did not.
In their analysis of the 1982 National Survey of Family Growth
(included in Tables 3.7 and 3.8), Pamuk et al. noted important racial
differences in the influence of pregnancy wantedness on use of prenatal
care. They concluded that for white women, whether or not a pregnancy
was wanted had only a small effect on adequacy of prenatal care.
Among blacks, however, a birth conceived by a woman who did not want to become
pregnant (again) is considerably less likely to receive adequate prenatal care, regardless
of the mother's age, number of previous births, marital status, or her financial access to
care. This fact becomes particularly important when tone considers] that approxi-
mately 22 percent of births to black women fit the definition of being "unwanted" at
108
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
TABLE 3.8 Factors Found to Predict Insufficient Use of Prenatal Care
in Multivariate Analysisa
Odds
Factor Ratio r2 Comments
Duke et al.; Less education 1.4 NA Age and race not
Oklahoma Greater economic barriers 0.66 found significant
to care (difficulty paying
for care, more reliance on
public financial support
and public insurance)
More access barriers 1.23
(transportation problems,
appointment delays, etc.)
Mother unemployed 1.28
Less social support from 1.22
baby's father
Johnson et al.; Unmarried 2.0 NA Outcome measure
Massachusetts Higher parity 2.1 was adequacy of
Younger 1.4 prenatal care
Lower income 1.4-1.6 (Kessner); also
Longer interval until NA trimester of
woman "knew I was registration
pregnant"
Pregnancy unplanned 1.8
Dissatisfied with prenatal 1.2 Analysis controlled
care for socioeconomic
No health insurance 2.3 factors; race not
during pregnancy found significant
Used hospital clinic for 1.5
prenatal care
Had no one to care for 1.7
other children
Had never used [this] 1.4
health care site before
Medicaid insured 1.6
Less education NA
Poland, et al.; Less insurance
Detroit Negative initial attitude
toward pregnancy
Longer interval until
pregnancy suspected
Less favorable attitude
toward health
professionals
Less importance accorded
prenatal care
Delay in telling others of
pregnancy
NA
.49
Age, parity,
maternal risk,
and substance
abuse not found
·<
slgnmcant
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
TABLE 3.8 Continued
109
Study
Factor
Odds
Ratio r2 Comments
Bowling and
Riley; North
Carolina
Learner et al.;
South
Carolina
Not a WIC recipient
Pregnancy diagnosed by
neither doctor nor health
department
Lower income (<$10,000)
Higher parity
Younger
Unplanned pregnancy
Not employed full-time
No private insurance
No Medicaid
Black
No regular physician
Greater financial burdens (lack
of money or insurance or
both)
More transportation problems
More problems with child care
Later awareness of the
pregnancy
Higher parity
Swink; Less education
Oklahoma Money problems
Less social support
Longer interval since last
physician visit
Less importance given to
seeing an M.D. as soon as
pregnancy known
Pregnancy outcome not
believed to be significantly
affected by prenatal care
Kalmuss et al.; Younger
New York Larger number of difficulties
City reported in getting care
Less education
Negative attitude toward
health care providers
Absence of insurance
Lower value attached to
prenatal care
Used drugs during pregnancy
Fewer positive health-related
behaviors during pregnancy
17.8 NA Only study that
5.4~.17 found Medicaid
2.94
0.71
'1.12
2.91
2.36
2.27
1.29
0.29
2.72
2.10
2.92
2.62
2.39
2.26
0.39
3.49
0.14
1.05
0.17
.27
NA .34
increases
probability of
sufficient care
Continued
110
TABLE 3.8 Continued
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
Study
Factor
Odds
Ratio r2 Comments
Warrick; Maricopa
County, Arizona
Hispanic
Non-
Hispanic,
white
Durrick and
Leonardson;
South Dakota
McDonald and
Cobrun;
Wisconsin
Maine
Low perception of
efficacy of care
Don't know where to
go for care
Higher parity
Not living in
metropolitan Phoenix
Unmarried
Low perception of
efficacy of care
Less adequate insurance
Had not seen a dentist
in past 2 years
More afraid of seeing
M.D.
More [sic] years in the
community
Financial loss in last
year
Complications in
pregnancy
Absence of private
insurance
Lower income
Higher parity
Care paid by Medicaid
Care paid by self
Pregnancy unplanned
Younger
Care paid by Medicaid
Region in state
Care paid by self
Unplanned pregnancy
Lower income
Greater travel time to
care
NA .35
NA .36
NA .28
NA .13
NA .096
Outcome measure for
all four state
analyses
summarized here
was month care
begun; analyses
also done using
ratio of actual to
"prescribed"
number of visits
and Kessner index
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
TABLE 3.8 Continued
111
Odds
Study Factor Ratio r2 Comments
Texas Care not provided in private NA .26
physician's office
Region in state
Less education
Lower income
Pregnancy unplanned
Higher parity
Hispanic
Colorado Unmarried NA .23
Region in state
Lower income
Greater travel time to care
Unplanned pregnancy
Care paid by Medicaid
Less education
Hispanic
Pamuk et al.;
United States
White, Less insurance
non-Hispanic
Black, Younger
non-Hispanic Higher parity
Unwanted pregnancy
Imershein et al.;
Florida
Later confirmation of
pregnancy
Use of hospital emergency
room as primary source of
medical care
Younger
Less education
Unmarried
Higher parity
NA NA
NA NA
NA .38
NOTE: NA indicates data not available.
aOnly factors significant at p ' .05 are recorded.
conception compared to only 8 percent of births to white women. The difference
between the two race groups with respect to both the degree of unwanted childbearing
and its consequences for obtaining adequate prenatal care is striking and seems to
imply differing degrees of access to or use of effective birth control and/or resort to
abortion when an unwanted pregnancy does occur.32
112
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
It is important to add that the data set used in this analysis does not permit
one to control for socioeconomic status. In one study that did hold
socioeconomic status constant (a study of very poor women in Harlem),
intendedness of pregnancy bore no statistically significant relationship to
early enrollment in prenatal care.33
Fourth, multivariate analysis seems to confirm a finding from the direct
interviews of women, noted above: a major obstacle to enrolling some
women in care is their view that it is of limited value or, perhaps more
accurately, that other concerns are more important. These studies also
suggest that women who secure insufficient prenatal care are less well
linked to the health care system overall and report more negative attitudes
toward health care providers.
Finally, the prominence of parity is noteworthy. Although many women
obtain prenatal care for the first or second pregnancy, they may not do so
for later pregnancies. Problems with child care, finances, and other family
responsibilities may account for this trend. Perhaps, after a few pregnancies,
a woman feels she understands the likely course of events, intending to seek
care only if she detects a developing problem. Earlier experiences with
prenatal care may also have been unsatisfying; perhaps the care was poorly
explained, felt to be of uncertain value, or offered in an unacceptable manner.
The multivariate analyses confirm many of the risk factors for insuffi-
cient prenatal care outlined in Chapter 1- poverty, being unmarried,
under 20, higher parity, and less than a high school education. The
multivariate analyses add to this list unintended pregnancy, little value
attached to prenatal care, tenuous connection to the health care system,
and negative attitudes toward providers. Among the vast majority of these
studies, race was not found to predict insufficient care.
These multivariate studies can assist in designing programs to improve
participation in prenatal care. They help to define key risk factors and
therefore can be used to identify target groups. It is important to
acknowledge nonetheless that there is still much that is not known about
the factors that influence participation in prenatal care (as evidenced, for
example, by the relatively low r2 values shown in Table 3.89. The
demographic risk factors outlined in Chapter 1, for example, are only
partially helpful in defining target groups. Race, low educational attain-
ment and young maternal age all correlate with poverty and within poor
groups lose their discriminatory power. That is, even within seemingly
homogeneous tow-income groups, use of prenatal care can vary apprecia-
bly, demonstrating the need for more sophisticated understanding of the
factors influencing this health behavior.
WOMEN'S PERCEPTIONS OF BARRIERS TO CARE
SUMMARY
113
This chapter has presented three data sets that bring some rank order to
the many factors reported to limit use of prenatal care. Surveys of clients
show that although many factors keep women out of care, financial
burdens, particularly inadequate insurance, are indisputably the most
significant. Other important barriers reported by women include limited
appreciation of the need for, or value of, prenatal care and a variety of
well-known barriers to access, such as difficulty obtaining transporta-
tion. Obstetricians seem to agree with clients on the relative importance
of specific barriers to care. Finally, sets of factors found by multivariate
analysis to predict insufficient prenatal care include many of the
demographic risk factors discussed in Chapter 1 though not generally
race plus unintended pregnancy, low value attached to prenatal care,
poor links to the health care system generally, and negative attitudes
toward providers.
REFERENCES
1. Russet RE. The first report on the Lea County survey of women who have delivered
babies while residents of Lea County during 197~1981. Hobbs, N. Mex.: Lea
County Perinatal Program, 1982.
2. Swink C. A comparative study of users and nonusers of prenatal care services.
Ph.D. diss. University of Oklahoma, 1985.
3. Duke JC, dePersio SR, Nimmo KE, and Lorenze RR. Convenience Disincentives
and Pregnancy Desire in Relationship to Prenatal Care. Oklahoma City: Oklahoma
State, Department of Health, 1987.
4. Johnson S. Gibbs E, Kogan M, Knapp C, and Hansen OH. Massachusetts Prenatal
Care Survey Factors Related to Prenatal Care Utilization. Boston: SPRANS
Prenatal Care Project, Massachusetts Department of Public Health, 1987.
S. Toomey BG. Factors Related to Early Entry into Prenatal Care: A Replication.
Columbus: Bureau of Maternal and Child Health, Ohio Department of Health,
198S.
6. Mertens D. Birth Certificate Survey on Access to Prenatal and Well Child Care.
Springfield: Illinois Department of Public Health, 1987.
7. Oxford L, Schinfeld SG, Elkins TE, and Ryan GM. Deterrents to early prenatal care.
J. Tenn. Med. Assoc. November:691-695, 198S.
8. Johnson CD and Mayer JP. Texas OB Survey: Determining the Need for Maternity
Services in Texas. College Station, Tex.: Public Policy Resources Laboratory, 1987.
9. Learner M, Stephens T. Sears OH, and Efirt C. Prenatal Care in South Carolina:
Results from the Prenatal Care Survey. Columbia: Department of Health and
Environmental Control, 1987.
10. Beatley S. Barriers to Prenatal Care in the Denver Health and Hospital System.
Denver: Colorado Department of Health, 1985.
11. 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.
114
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
12. Lake M and Nixon D. A Study of Childbearing Women at a Public Hospital in
Tampa. Tampa: University of South Florida, 1985.
13. 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.
14. Bowling1M and Riley P. Access to Prenatal Care in North Carolina. Raleigh: North
Carolina State Center for Health Statistics, 1987.
IS. U.S. General Accounting Office. Prenatal Care: Medicaid Recipients and Uninsured
Women Obtain Insufficient Care. Pub. No. GAO/HRD-87-137. Washington, D.C.:
Government Printing Office, 1987.
16. Richwald GA, Rhodes K, Kersey L, and Silberman LA. No Prenatal Care Study at
Los Angeles County/USC Medical Center Women's Hospital. Los Angeles: Univer-
sity of California at Los Angeles, School of Public Health, 1987.
17. Imershein A, Meachen S. Kelley S. and Rand P. A Survey and Analysis of Barriers
to Prenatal Care in Florida's Improved Pregnancy Outcome Outreach Project.
Tallahassee: Center for Human Services Policy and Administration, 1988.
18. Christison-Lagay] and Crabtree BF. Barriers Affecting Entry into Prenatal Care. A
Study of Adolescents Under 18 in Hartford, Connecticut. Hartford: City of
Hartford Health Department, 1984.
19. Kalmuss D et al. Op. cit., pp. 72-74.
20. Richwald G et al. Op. cit.
21. Kalmuss D et al. Op. cit.
22. Joyce K, Diffenbacher G. Greene I, and Sorokin Y. Internal and external barriers to
obtaining prenatal care. Soc. Work Health Care 9:89-96, 1983.
23. See Johnson S et al. Op. cit.; Learner M et al. Op. Cit.; and Christison-Lagay J and
Crabtree BF. Op. cit.
24. Christison-Lagay J and Crabtree BF. Op. cit., p. 28.
25. American College of Obstetricians and Gynecologists, Committee on Health Care
for Underserved Women. Ob/Gyn Services for Indigent Women: An ACOG
Survey. Washington, D.C., 1988.
26. See Swink C. Op. Cit.; Duke JC et al. Op. cit.; Johnson S et al. Op. Cit.; Learner M
et al. Op. cit.; Kalmuss D et al. Op. cit.; Bowling EM and Riley P. Op. cit.; and
Imershein A et al. Op. cit.
27. 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.
28. Durrick SK and Leonardson GR. Profile of adequate and inadequate prenatal care
persons. Pierre, S. Dak.: South Dakota Department of Health, 1985.
29. Poland ML, Ager IW, and Olson JM. Barriers to receiving adequate prenatal care.
Am. I. Obstet. Gynecol. 157:297-303, 1987.
30. 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.
31. 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.
32. Pamuk ER et al. Op. cit., p. 13.
33. McCormick MC, Brooks-Gunn J. Shorter T. Wallace CY, Holmes]H, and Haegarty
MC. The planning of pregnancy among low-income women in central Harlem. Am.
J. Obstet. Gynecol. 156:145-149, 1987.
