Click for next page ( 89


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



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 88
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 yearswere 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 88
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 88
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 88
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 88
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 88
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 88
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 . ,= ~ Z ~ :^ P~ - L~ O .5-~ ~ c Z (,: e . - . 4= C~ u) 0d . o L4 ~2 `.~-1 P~ o . e~ . . 3

OCR for page 88
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 - - - = - ~

OCR for page 88
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

OCR for page 88
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

OCR for page 88
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 88
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 ._

OCR for page 88
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 ~ ~ -

OCR for page 88
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 examplethat 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

OCR for page 88
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

OCR for page 88
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

OCR for page 88
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

OCR for page 88
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

OCR for page 88
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.

OCR for page 88
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.

OCR for page 88
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.