Soc. Sci. Med. Vol. 30, No. 4, pp. 487-495, 1990
0277-9536/90 $3.00 + 0.00 Copyright © 1990 Pergamon Press plc
Printed in Great Britain. All rights reserved
BARRIERS A N D MOTIVATORS TO PRENATAL CARE A M O N G LOW-INCOME WOMEN BETTY LIA-HOAGBERG,l* PETER RODE,2 CATHERINEJ. SKOVHOLT,l CHARLES N. OBERG,3 CYNTHIA BERG,4 SARA MULLETT5 and THOMASCHOI 1 tUniversity of Minnesota, School of Public Health, Minneapolis, MN 55455, 2Urban Coalition of Minneapolis, MN 55415, 3Hennepin County Medical Center, Minneapolis, MN 55415, 4Center for Disease Control, Atlanta, GA 30333 and 5Minnesota Department of Health, Minneapolis, MN 55416, U.S.A. Abstract--Substantial evidence exists which links prenatal care to improved birth outcomes. However, low-income and nonwhite women in the United States, who are at greatest risk for poor birth outcomes, continue to receive the poorest prenatal care. The purpose of this study was to identify and compare barriers and motivators to prenatal care among women who lived in low-income census tracts. The stratified sample included recently delivered white, black and American Indian women who received adequate, intermediate, and inadequate prenatal care. Interviews were conducted which focused primarily on the women's perceptions of problems in obtaining prenatal care and getting to appointments. Results indicated that women with inadequate care identified a greater number of barriers and perceived them as more severe. Psychosocial, structural, and socio-demographic factors were the major barriers, while the mother's beliefs and support from others were important motivators. The predictive power of selected barrier variables was examined by a regression analysis. These variables accounted for 50% of the variance in prenatal care use. The results affirm the complexity of prenatal care participation behavior among low-income women and the dominant influence of psychosocial factors. Comprehensive, coordinated and multidisciplinary outreach and services which address psychosocial and structural barriers are needed to improve prenatal care for low-income women. Key words--prenatal care, low income women, barriers, psychosocial factors
INTRODUCTION
rates have continued at the same level for the past 3 years [20-23]. According to the Department of Health and H u m a n Services, about 80% of females at high risk for having a low birth-weight infant could be identified at the first prenatal care visit and appropriate interventions could be taken [11]. However, these women are also least likely to seek early and continuous prenatal care [23, 24]. Prenatal care not only saves infants' lives, it is also cost effective [25]. The Institute of Medicine report on low birth-weight indicates that every dollar spent on prenatal care for high-risk pregnant women saves U.S. $3.38 in medical care [26]. The Childrens' Defense Fund emphasizes that it costs about U.S. $600 to provide a pregnant women with comprehensive prenatal care services throughout her pregnancy, while the cost for neonatal intensive care is about U.S. $1000 per day [27]. The emotional costs of having a high-risk infant are more difficult to measure. However, research verifies both the emotional and economic stress on families of infants with significant medical impairment [28]. The high financial, social, and emotional costs of LBW make it imperative to understand the factors which prevent high-risk women from obtaining the care they need. Studies on medical, dental, mental health, and geriatric populations have identified three major categories of deterrents to health care, including structural, individual, and socio-demographic barriers [29]. Structural barriers include organization of services, availability of care, time, costs, and similar factors. Individual barriers are those related to the client/patient, such as knowledge, feelings, and attitudinal factors.
Prenatal care is a major factor in preventing low birth-weight and other adverse pregnancy outcomes [1-5]. W o m e n with no prenatal care are three times more likely to have low birth-weight babies ( < 2500 g or 5.5 lb) than mothers with early and continuous prenatal care [6, 7]. Low birth-weight accounts for two-thirds of infant deaths during the first month of life and half of all infant deaths in the first year of life [8, 9]. Infants born at low birth-weight are also more likely to develop chronic and handicapping conditions [10]. Low-income and minority women (blacks, American Indian and others) are at greatest risk for delivery of a low birth-weight infant [11, 12]. National studies in the United States suggest that prenatal care provides greater benefits for infants born to this high-risk group than to low-risk groups [13-17]. Data from 1985 indicate that 76.2% of all United States infants were born to women who started prenatal care in the first 3 months of pregnancy [18]. However in 1986 a higher percentage of babies (6%) were born to mothers who received late or no prenatal care than in 1980 (5.1%) [19]. The proportions of women with no care also varies strikingly by race. Third trimester or no prenatal care was reported for 5% of white mothers, 10% of black mothers, and 12.3% for American Indian mothers [18, 20]. These *Address correspondence to: Betty Lia-Hoagberg, Division of Human Development and Nutrition, School of Public Health, Box 197 UMHC, University of Minnesota, Minneapolis, MN 55455, U.S.A. 487
488
BETTY LIA-HOAGBERG et al.
Recent studies of prenatal care services have also identified barriers which help explain why women obtain inadequate care. A structural factor, lack of financial resources or insurance coverage, has consistently emerged as the most critical barrier [30-35]. However recent research indicated that receipt of Medicaid (a public source of health care financing for low income individuals) does not insure use of prenatal care [36]. An estimated 26% 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 health insurance at all [37]. Other significant barriers associated with reduced prenatal care participation were inadequate access to transportation and child care [30]. Individual factors identified as important barriers included fear and delay in disclosing the pregnancy, fear of medical procedures, feeling that prenatal care was unimportant, and the presence of multiple personal and family problems [38-40]. Socio-demographic factors, including maternal age, marital status, financial status, educational level, and parity have also been associated with level of prenatal care [30-32]. Vital statistics have consistently documented the major differences among racial groups in prenatal care use. However, few studies have systematically sampled women from specific racial backgrounds by level of prenatal care. In addition, there has been a lack of emphasis on women's perceptions of their prenatal care [18]. While studies have focused on barriers to prenatal care, very little is known about motivators. The existing motivation literature includes limited information on factors that encourage or support prenatal care use [41-44]. The purpose of the study was to identify and compare barriers and motivators associated with prenatal care use among three groups of low-income women: white, black, and American Indian. Barriers were defined as those factors, perceived and unperceived, which were associated with delays in starting care or with infrequent care. Motivators were those factors which encouraged mothers to obtain and continue prenatal care.
METHOD
The study was conducted with a stratified sample of recently delivered white, black and American Indian women who received adequate, intermediate and inadequate care. The stratification was designed to assure approximately equal representation of all nine subgroups (Table 1). The women were interviewed in one public and four private hospitals in a Table 1. Study subjects Care level Race
Adequate
Intermediate
Inadequate
White
25
24
18
Total 67
(31.8%) Black
24
23
28
75
(35.5%) American Indian Total
16
26
27
69 (32.7%)
65 (30.8%)
73 (34.6%)
73 (34.6%)
211 (100%)
midwest city in the United States between October 1986 and June 1987. Hospitals which served pregnant, low-income women were selected as study sites. Participants were selected from 41 census tracts where at least 20% of residents were living at or below the poverty level according to the 1980 census. Subjects were sampled proportionately from each study hospital, based on the number of births from the selected low-income census tracts. In addition, women were sampled within each study hospital by race and by care level to reflect that institution's birth records from the previous year. Level of care was assessed using the modified Kessner Index, which combines trimester prenatal care was started and number of visits, and adjusts for gestational age at birth to determine level of care (see Appendix) [45]. Quality of care is not assessed by the Kessner Index. Potential subjects were screened on a daily basis at the five hospitals to determine study eligibility. Subjects were interviewed following delivery by a trained interviewer of their own race and were paid for their participation. Ninety-five percent of the interviews were completed in the hospital and 5% were done at home within 2 weeks of the delivery. Data were obtained in a 50-min structured interview using a pretested questionnaire with items derived from a review of previous research and an expert panel of providers. The interview was pilot tested and reviewed by perinatal care providers for content validity. The interview included sections on socio-demographic data, reproductive history, and structural and individual psychosocial factors related to prenatal care use. The structural section included questions on experiences with the health care system, transportation, child care, and finances. The individual psychosocial section focused on attitudes and feelings about the pregnancy and prenatal care. The interview included open-ended and forced-choice questions. Responses to open-ended questions were recorded in the subject's own words. Barriers to prenatal care were assessed with two different sets of questions. First, the women were asked if a particular factor (such as transportation) was a problem (barrier) for them in obtaining prenatal care. Then additional questions were asked to assess if these same factors were reasons for the women to miss prenatal appointments. Demographic data and information on prenatal care participation were gathered from the medical record. After a content analysis was done, responses were scored by two independent raters with extensive experience in the perinatal health field. Scoring discrepancies were minimal and decisions on discrepancies were reached by discussion and mutual agreement between raters. If a consensus on scoring was not reached between raters, the item was deleted from analysis. Of the 242 women contacted who met study criteria, 211 (87%) agreed to participate and 31 (13%) declined. Analysis of participants and nonparticipants indicated no significant differences on age, marital status, education or income level. The study was designed to include women in each care level, with equal representation from the three racial groups. Final study participants included 67 white, 75 black, and 69 American Indian women (Table 1). The
489
Barriers and motivators to p r e n a t a l care Table 2. Socio-demographicfactors by levelof care Adequate
Intermediate
Inadequate
(n = 65)
(n = 73)
(n = 73)
Total Chi-square significance
n
(%)
n
(%)
n
(%)
n
(%)
7 57
(11) (89)
18 55
(25) (75)
22 51
(30) (70)
47 163
(22) (78)
7.57*
33 23 9
(51) (35) (14)
47 15 10
(65) (21)
56 8
(65) (11)
136 46
(65) (22)
3.32t
(14)
8
(11)
27
(13)
20 15 25
(33) (25) (42)
34 13 23
(49) (19) (33)
35 20 10
(54) (31) (15)
89 48 58
(46) (25) (30)
2.73*
43 20
(64) (32)
52 20
(72) (28)
58 12
(83) (11)
153 52
(75) (25)
4.08NS
32 33
(49) (51)
51 22
(70) (30)
55 18
(75) (25)
138 73
(65) (35)
11.34t
31 25 8
(48) (39) (13)
20 43 7
(29) (61) (10)
21 45 6
(29) (63) (8)
72 113 21
(35) (55) (10)
9.64*
52 13
(80) (20)
49 24
(67) (33)
41 32
(56) (44)
142 69
(67) (33)
8.88*
33 40
(44) (56)
20 53
(27) (73)
82 129
(39) (61)
5.90 NS
Mother's age
0277-9536/90 $3.00 + 0.00 Copyright © 1990 Pergamon Press plc
Printed in Great Britain. All rights reserved
BARRIERS A N D MOTIVATORS TO PRENATAL CARE A M O N G LOW-INCOME WOMEN BETTY LIA-HOAGBERG,l* PETER RODE,2 CATHERINEJ. SKOVHOLT,l CHARLES N. OBERG,3 CYNTHIA BERG,4 SARA MULLETT5 and THOMASCHOI 1 tUniversity of Minnesota, School of Public Health, Minneapolis, MN 55455, 2Urban Coalition of Minneapolis, MN 55415, 3Hennepin County Medical Center, Minneapolis, MN 55415, 4Center for Disease Control, Atlanta, GA 30333 and 5Minnesota Department of Health, Minneapolis, MN 55416, U.S.A. Abstract--Substantial evidence exists which links prenatal care to improved birth outcomes. However, low-income and nonwhite women in the United States, who are at greatest risk for poor birth outcomes, continue to receive the poorest prenatal care. The purpose of this study was to identify and compare barriers and motivators to prenatal care among women who lived in low-income census tracts. The stratified sample included recently delivered white, black and American Indian women who received adequate, intermediate, and inadequate prenatal care. Interviews were conducted which focused primarily on the women's perceptions of problems in obtaining prenatal care and getting to appointments. Results indicated that women with inadequate care identified a greater number of barriers and perceived them as more severe. Psychosocial, structural, and socio-demographic factors were the major barriers, while the mother's beliefs and support from others were important motivators. The predictive power of selected barrier variables was examined by a regression analysis. These variables accounted for 50% of the variance in prenatal care use. The results affirm the complexity of prenatal care participation behavior among low-income women and the dominant influence of psychosocial factors. Comprehensive, coordinated and multidisciplinary outreach and services which address psychosocial and structural barriers are needed to improve prenatal care for low-income women. Key words--prenatal care, low income women, barriers, psychosocial factors
INTRODUCTION
rates have continued at the same level for the past 3 years [20-23]. According to the Department of Health and H u m a n Services, about 80% of females at high risk for having a low birth-weight infant could be identified at the first prenatal care visit and appropriate interventions could be taken [11]. However, these women are also least likely to seek early and continuous prenatal care [23, 24]. Prenatal care not only saves infants' lives, it is also cost effective [25]. The Institute of Medicine report on low birth-weight indicates that every dollar spent on prenatal care for high-risk pregnant women saves U.S. $3.38 in medical care [26]. The Childrens' Defense Fund emphasizes that it costs about U.S. $600 to provide a pregnant women with comprehensive prenatal care services throughout her pregnancy, while the cost for neonatal intensive care is about U.S. $1000 per day [27]. The emotional costs of having a high-risk infant are more difficult to measure. However, research verifies both the emotional and economic stress on families of infants with significant medical impairment [28]. The high financial, social, and emotional costs of LBW make it imperative to understand the factors which prevent high-risk women from obtaining the care they need. Studies on medical, dental, mental health, and geriatric populations have identified three major categories of deterrents to health care, including structural, individual, and socio-demographic barriers [29]. Structural barriers include organization of services, availability of care, time, costs, and similar factors. Individual barriers are those related to the client/patient, such as knowledge, feelings, and attitudinal factors.
Prenatal care is a major factor in preventing low birth-weight and other adverse pregnancy outcomes [1-5]. W o m e n with no prenatal care are three times more likely to have low birth-weight babies ( < 2500 g or 5.5 lb) than mothers with early and continuous prenatal care [6, 7]. Low birth-weight accounts for two-thirds of infant deaths during the first month of life and half of all infant deaths in the first year of life [8, 9]. Infants born at low birth-weight are also more likely to develop chronic and handicapping conditions [10]. Low-income and minority women (blacks, American Indian and others) are at greatest risk for delivery of a low birth-weight infant [11, 12]. National studies in the United States suggest that prenatal care provides greater benefits for infants born to this high-risk group than to low-risk groups [13-17]. Data from 1985 indicate that 76.2% of all United States infants were born to women who started prenatal care in the first 3 months of pregnancy [18]. However in 1986 a higher percentage of babies (6%) were born to mothers who received late or no prenatal care than in 1980 (5.1%) [19]. The proportions of women with no care also varies strikingly by race. Third trimester or no prenatal care was reported for 5% of white mothers, 10% of black mothers, and 12.3% for American Indian mothers [18, 20]. These *Address correspondence to: Betty Lia-Hoagberg, Division of Human Development and Nutrition, School of Public Health, Box 197 UMHC, University of Minnesota, Minneapolis, MN 55455, U.S.A. 487
488
BETTY LIA-HOAGBERG et al.
Recent studies of prenatal care services have also identified barriers which help explain why women obtain inadequate care. A structural factor, lack of financial resources or insurance coverage, has consistently emerged as the most critical barrier [30-35]. However recent research indicated that receipt of Medicaid (a public source of health care financing for low income individuals) does not insure use of prenatal care [36]. An estimated 26% 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 health insurance at all [37]. Other significant barriers associated with reduced prenatal care participation were inadequate access to transportation and child care [30]. Individual factors identified as important barriers included fear and delay in disclosing the pregnancy, fear of medical procedures, feeling that prenatal care was unimportant, and the presence of multiple personal and family problems [38-40]. Socio-demographic factors, including maternal age, marital status, financial status, educational level, and parity have also been associated with level of prenatal care [30-32]. Vital statistics have consistently documented the major differences among racial groups in prenatal care use. However, few studies have systematically sampled women from specific racial backgrounds by level of prenatal care. In addition, there has been a lack of emphasis on women's perceptions of their prenatal care [18]. While studies have focused on barriers to prenatal care, very little is known about motivators. The existing motivation literature includes limited information on factors that encourage or support prenatal care use [41-44]. The purpose of the study was to identify and compare barriers and motivators associated with prenatal care use among three groups of low-income women: white, black, and American Indian. Barriers were defined as those factors, perceived and unperceived, which were associated with delays in starting care or with infrequent care. Motivators were those factors which encouraged mothers to obtain and continue prenatal care.
METHOD
The study was conducted with a stratified sample of recently delivered white, black and American Indian women who received adequate, intermediate and inadequate care. The stratification was designed to assure approximately equal representation of all nine subgroups (Table 1). The women were interviewed in one public and four private hospitals in a Table 1. Study subjects Care level Race
Adequate
Intermediate
Inadequate
White
25
24
18
Total 67
(31.8%) Black
24
23
28
75
(35.5%) American Indian Total
16
26
27
69 (32.7%)
65 (30.8%)
73 (34.6%)
73 (34.6%)
211 (100%)
midwest city in the United States between October 1986 and June 1987. Hospitals which served pregnant, low-income women were selected as study sites. Participants were selected from 41 census tracts where at least 20% of residents were living at or below the poverty level according to the 1980 census. Subjects were sampled proportionately from each study hospital, based on the number of births from the selected low-income census tracts. In addition, women were sampled within each study hospital by race and by care level to reflect that institution's birth records from the previous year. Level of care was assessed using the modified Kessner Index, which combines trimester prenatal care was started and number of visits, and adjusts for gestational age at birth to determine level of care (see Appendix) [45]. Quality of care is not assessed by the Kessner Index. Potential subjects were screened on a daily basis at the five hospitals to determine study eligibility. Subjects were interviewed following delivery by a trained interviewer of their own race and were paid for their participation. Ninety-five percent of the interviews were completed in the hospital and 5% were done at home within 2 weeks of the delivery. Data were obtained in a 50-min structured interview using a pretested questionnaire with items derived from a review of previous research and an expert panel of providers. The interview was pilot tested and reviewed by perinatal care providers for content validity. The interview included sections on socio-demographic data, reproductive history, and structural and individual psychosocial factors related to prenatal care use. The structural section included questions on experiences with the health care system, transportation, child care, and finances. The individual psychosocial section focused on attitudes and feelings about the pregnancy and prenatal care. The interview included open-ended and forced-choice questions. Responses to open-ended questions were recorded in the subject's own words. Barriers to prenatal care were assessed with two different sets of questions. First, the women were asked if a particular factor (such as transportation) was a problem (barrier) for them in obtaining prenatal care. Then additional questions were asked to assess if these same factors were reasons for the women to miss prenatal appointments. Demographic data and information on prenatal care participation were gathered from the medical record. After a content analysis was done, responses were scored by two independent raters with extensive experience in the perinatal health field. Scoring discrepancies were minimal and decisions on discrepancies were reached by discussion and mutual agreement between raters. If a consensus on scoring was not reached between raters, the item was deleted from analysis. Of the 242 women contacted who met study criteria, 211 (87%) agreed to participate and 31 (13%) declined. Analysis of participants and nonparticipants indicated no significant differences on age, marital status, education or income level. The study was designed to include women in each care level, with equal representation from the three racial groups. Final study participants included 67 white, 75 black, and 69 American Indian women (Table 1). The
489
Barriers and motivators to p r e n a t a l care Table 2. Socio-demographicfactors by levelof care Adequate
Intermediate
Inadequate
(n = 65)
(n = 73)
(n = 73)
Total Chi-square significance
n
(%)
n
(%)
n
(%)
n
(%)
7 57
(11) (89)
18 55
(25) (75)
22 51
(30) (70)
47 163
(22) (78)
7.57*
33 23 9
(51) (35) (14)
47 15 10
(65) (21)
56 8
(65) (11)
136 46
(65) (22)
3.32t
(14)
8
(11)
27
(13)
20 15 25
(33) (25) (42)
34 13 23
(49) (19) (33)
35 20 10
(54) (31) (15)
89 48 58
(46) (25) (30)
2.73*
43 20
(64) (32)
52 20
(72) (28)
58 12
(83) (11)
153 52
(75) (25)
4.08NS
32 33
(49) (51)
51 22
(70) (30)
55 18
(75) (25)
138 73
(65) (35)
11.34t
31 25 8
(48) (39) (13)
20 43 7
(29) (61) (10)
21 45 6
(29) (63) (8)
72 113 21
(35) (55) (10)
9.64*
52 13
(80) (20)
49 24
(67) (33)
41 32
(56) (44)
142 69
(67) (33)
8.88*
33 40
(44) (56)
20 53
(27) (73)
82 129
(39) (61)
5.90 NS
Mother's age
