The European Journal of Contraception and Reproductive Health Care, 2014; 19: 220–226
Characteristics and prenatal care utilisation of Romanian pregnant women Ecaterina Stativa*, Adrian V. Rus†, Nicolae Suciu*, Jacquelyn S. Pennings‡, Max E. Butterfield § , Reggies Wenyika† and Rebecca Webster † *The
Institute for Mother and Child Care ‘Alfred Rusescu’, Bucharest, Romania, † Behavioral Science Department, Southwestern Christian University, Oklahoma, USA, ‡Elite Research, LLC, Carrollton, Texas, USA, and §Psychology Department, Point Loma Nazarene University, California, USA
............................................................................................................................................................................................................
ABSTRACT
Objective To describe the degree to which Romanian women access free prenatal care services, and to describe the demographic profile of women who are at risk for underutilisation. Methods Secondary data (n ⫽ 914) were taken from a large, nationally representative sample of Romanian mothers and children (N ⫽ 2117). Kotelchuck’s Adequacy of Prenatal Care Utilisation Index was used to measure the adequacy of prenatal care. Results Seventy-eight percent of mothers underutilised prenatal care services. Those who did so to the greatest degree were likely to be young, members of an ethnic minority, poor, uneducated, and rural. Conversely, those who utilised care to the greatest degree were likely to be older, members of the ethnic majority, wealthy, educated, and city dwelling. Conclusion Despite the fact that many of the risk factors for underutilisation in this sample were similar to those found elsewhere in Europe and the developed world, these findings illustrate the worrisome magnitude of the problem in Romania, particularly among women with low levels of income and educational attainment. Future studies should examine factors that contribute to underutilisation, whether it corresponds to negative health outcomes, and whether targeted social interventions and outreach could help improve care.
K E Y WO R D S
Maternal health services; Maternal welfare; Obstetric care; Prenatal care; Romania
I N T RO D U C T I O N
The collapse of the Romanian communist regime in 1989 marked a new era for women’s health initiatives in Romania. Of particular note, health officials began implementing a comprehensive prenatal
care programme designed to increase positive health outcomes for infants and mothers1. The Ministry of Health adopted a standard of prenatal care practices similar to those prevailing in other developed countries2–4, and all women became eligible for a range of free prenatal care services, including risk assessments,
Correspondence: Adrian V. Rus, PhD, Southwestern Christian University, Behavioral Sciences Department, 7210 NW 39th Expressway, Bethany, OK 73008-0340, USA. Tel: ⫹ 1 405 789 7661, ext. 3450. Fax: ⫹ 1 405 495 0078. E-mail: [email protected]
© 2014 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2014.907399
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medical examinations, laboratory tests and screenings, behavioural screenings, and prenatal counselling sessions5–7. However, more than a decade after reforms were initiated (in 2001), nearly nine in ten Romanian mothers across the social strata still did not receive adequate prenatal services8. The widespread lack of prenatal health care was particularly vexing in light of the fact that it came at no direct cost to consumers, and although initiatives to improve care have continued since that 2001 report, it was unclear whether pregnant women throughout the population were receiving insufficient prenatal attention9–11. As such, the primary objectives of the present study were twofold. The first objective was to access cross-sectional data from an existing dataset in order to determine current rates of care utilisation in Romania. The second objective was to explore whether demographic factors were associated with the quality of prenatal care. Ultimately, it was hoped that identification of such factors could be used in the future to aid public health efforts in Romania, as well as in other parts of the world. METHODS
Written consent was obtained from all participants before the study began and from the appropriate authorities. Specifically, the study was approved by the Institute for Mother and Child Care ‘Alfred Rusescu’ of Bucharest, Romania. This institution is under the authority of the Ministry of Health and its Board of Ethics and the Scientific Council approved the use of the data. The present study was also approved by the Institutional Review Board of Southwestern Christian University of Bethany, Oklahoma, United States. The data were drawn from a larger cross-sectional survey conducted during the second half of 2010, the Assessment of the Current Situation of Breastfeeding and Nutrition Practices for Children from Birth to Two Years Old12. This larger survey used a national family physician’s database and stratified, random sampling to select 2117 children aged 0–24 months. Respondents were selected with a sampling method that was designed primarily to control for any bias that could be caused by differences in population density (e.g., urban vs rural distinctions) across the country. The first step taken to ensure stratified random sampling that would be representative of all the macro-development regions of Romania was to randomly select two counties from
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each region for further sampling. From each of these counties, two urban localities and four or five villages were then randomly selected, as were two sectors of Bucharest (the largest city and capital of Romania) and one sector of the Bucuresti-Ilfov region that was not Bucharest.The random selection of these locations was made based on the lists of existing settlements in the Romanian Statistical Yearbook, 2009. In all, the resulting sample selected children from 16 Romanian counties, covering all eight macrodevelopment areas of the country. These children and their mothers were invited to the offices of their family physicians to answer a variety of health-related questions. There, 17 trained and experienced investigators collected the data using face-to-face interviews. The interviewers worked in groups of two to three individuals who verbally queried the mothers and then recorded the answers. To ensure consistency among researchers involved in data collection, all interview methods were thoroughly pre-tested (n ⫽ 80) before data collection was officially begun. The full data were collected over the course of four months between July 2010 and November 2010. To control for any interviewer-based errors and to ensure proper survey administration, the interview teams were supervised by research coordinators throughout the data collection process. From the larger sample, the mothers of children 12 months old and younger were asked an additional set of questions about their prenatal care. It was theorised that more recent care experiences would be more accurately remembered and reported, and so this measure was intended to maximise the accuracy with which respondents’ reported their care. More importantly, limiting the data to these women helped ensure that the data for the present study would reflect the most recent available trends in prenatal care utilisation. In all, these measures left a robust final sample of 914 respondents who were assessed in the present study. Seven socio-demographic variables of interest were used as categorical explanatory variables (EVs): age, ethnicity, marital status, education, location, socioeconomic status (SES), and parity. Age was recorded in years and divided into three categories: 15 to 19 years, 20 to 24 years, and 25 to 49 years. Ethnicity was coded as Romanian, Hungarian, or Roma. Marital status was coded as married or not married (including divorced, separated, widowed, or co-habiting). Education was coded into three categories based on years of school attended: gymnasium (0–8 years), high/technical school
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(9–12 years), and college (13 years or more). Location was coded as either urban or rural. SES was coded as low, medium, or high. To determine SES, participants were asked whether they owned 12 items: a stove, television, refrigerator, washing machine, mobile phone, flush toilet, central heating, private car, private housing, personal computer, video recorder, and vacation home. Participants who owned up to four goods or services were classified as low SES; those who owned at least five and up to eight were classified as medium SES; and those who owned at least nine were classified as high SES. Parity was coded as either no previous live birth or one or more previous live births. For each EV, the number of respondents concerned and the corresponding percentages are outlined in Table 1. The primary dependent measure was prenatal care utilisation, and it was assessed with the Adequacy of Prenatal Care Utilisation Index (APNCUI)13. The Table 1 Frequencies of respondents’ characteristics (N ⫽ 914). Characteristic Age 15 to 19 years 20 to 24 years 25 to 49 years Ethnicity Romanian Hungarian Roma Marital status Not married Married Education Gymnasium (0–8 years) High/Technical School (9–12 years) College (13 or more years) Location Urban Rural Socio-economic status Low Medium High Parity No previous live birth One or more previous live births ∗Due
n (%) ∗ 63 (7) 216 (24) 635 (70) 765 (84) 74 (8) 75 (8) 190 (21) 724 (79) 261 (29) 449 (49) 204 (22)
R E S U LT S 464 (51) 450 (49) 144 (16) 439 (48) 331 (36) 479 (52) 435 (48)
to rounding, the sum of the percentages in one case does not amount to 100%.
222
APNCUI is one of several widely used prenatal care indices, and it was selected for use here because it is an effective measure of prenatal care that has already taken place14. The care received by each respondent was rated as one of four possible categories of utilisation: inadequate, inadequate plus, adequate, and adequate plus. It is important to note that the ‘inadequate plus’ care is typically referred to as ‘intermediate’ care; however, it is used to describe a level of care that is less than adequate, and so it is referred to here as inadequate plus to avoid confusion. According to the APNCUI, inadequate care required either initiation of care after the 4th month of pregnancy or less than 50% of recommended visits; inadequate plus care required 50 to 79% of the recommended number of visits; adequate care required 80 to 109% of the recommended number of visits; and adequate plus care required 110% or more of the recommended number of visits. These last three categories all required initiation of care by the 4th month of pregnancy. Finally, it should be noted that the APNCUI is designed to avoid incorrectly attributing underutilisation of care to preterm birth (10% of the present sample) by adjusting the required number of visits according to gestational age at delivery. For cases in which gestational age at delivery is unavailable, it is imputed based on birth weight and child sex. The present study followed these guidelines in order to measure care as accurately as possible. Once the APNCUI was calculated, a series of crosstabulations with Pearson’s chi-squared and Cramer’s V was conducted to examine the relationship between the APNCUI scores and the levels of each of the seven EVs. To determine specifically how each EV affected care, z-tests of the proportions were conducted to illustrate differences between the categorical levels of each EV. All analyses were conducted using SPSS version 19.015.
Table 1 shows the frequency of each EV subcategory in the present sample. Table 2 shows the frequency of each level of care in the present sample. Overall, only 22% of mothers received at least an adequate level of care. The chi-squared analysis had revealed that each EV had a significant relationship with prenatal care utilisation (all p values ⬍ .01), and Table 3 illustrates these relationships. Pregnant women who received inadequate care were likely to be young (⬍ 25 years old), Roma,
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educated (⬎ 8 years), and they had no previous children; no differences were found between levels of age, location, or SES for mothers who received adequate care (Table 3, column 3). Finally, it is important to note that the proportion of mothers in the adequate plus category was quite low across all of the demographic characteristics (2–8%).The only exception was that pregnant women with no previous children were more likely to receive adequate plus care than were those who already had children (Table 3, column 4).
Table 2 Frequencies of adequacy of prenatal care variables (N ⫽ 914). Adequacy of Prenatal Care Utilisation Index Inadequate Inadequate Plus Adequate Adequate Plus
n
(%)
390 322 147 55
43 35 16 6
unmarried, uneducated, residing in a rural area, low in SES, and they had other children (Table 3, column 1). In contrast, women who received inadequate plus care were most likely to be older (⬎ 25 years old), Romanian or Hungarian, married, well educated (⬎ 12 years), city dwelling, and high in SES (Table 3, column 2). In further contrast, those who received adequate care were most likely to be Romanian, intermediately
DISCUSSION
Findings and interpretation Some 78% of women in the present study did not receive adequate antenatal guidance. Each of the following demographic variables was associated
Table 3 Frequencies for respondents’ characteristics by Adequacy of Prenatal Care Utilisation Index (N ⫽ 914). Inadequate Inadequate ⫹ n Age 15 to 19 years 20 to 24 years 25 to 49 years Ethnicity Romanian Hungarian Roma Marital status Not married Married Education No school/Gymnasium High/Technical school College Location Urban Rural Socio-economic status Low Medium High Parity No previous live birth Previous live births
39 104 247
%
n
62a 48a 39b
13 66 243
41a 35a 71b
277 33 12
59a 38b
45 277
58a 4b 28c
64 166 92
156 234
34a 52b
82 204 104
57a 47b 31c
311 26 53 112 278 152 181 57
174 216
36a 50b
%
Adequate Adequate ⫹ n
%
n
21a 31a 38b
10 16a 30 14a 107 17a
1 16 38
36a 45a 16b
131 17a 11 15a 5 7b
46 4 5
24a 38b
21 11a 126 17b
12 43
25a 37b 45c
30 12a 77 17b 40 20b
15 25 15
192 130
41a 29b
84 18a 63 14a
40 137 145
28a 31a 44b
17 12a 68 16a 62 19a
179 143
37a 33a
88 18a 59 14b
%
Total n
2a 7a 6a
63 100 216 100 635 100
6a 5a 7a
765 100 74 100 75 100
6a 6a
190 100 724 100
6a 6a 7a
261 100 449 100 204 100
32 23
7a 5a
464 100 450 100
5 30 20
4a 7a 6a
144 100 439 100 331 100
38 17
8a 4b
c2
%
Cramer’s V
19.54∗
.103
30.23∗∗
.129
27.78∗∗
.174
46.40∗∗
.159
31.80∗∗
.187
34.59∗∗
.138
20.22∗∗
.149
479 100 435 100
∗p ⬍ 0.01; ∗∗p ⬍ 0.001. Proportions with different subscripts within the same block (e.g., age) and column are significantly
different (p ⬍ 0.05). Differences are tested within demographic item using z-test of proportions.
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with decreased levels of care: young age, low socioeconomic status, status as an ethnic minority (Roma), unmarried status, fewer years of education, rural location, and previous children. Even though rates of care seeking were associated with these variables, most women from across these social strata are not receiving attention that can be described as adequate. For example, 73% of college-educated women received a level below adequate care, as did exactly the same percentage of women with little education (0–8 years). Differences in care were admittedly observed between these groups: educated women were much more likely to fall in the ‘inadequate plus category’, whereas women with little education were much more likely to fall in the ‘inadequate category’. However, the same percentage of both groups received adequate or better attention. Taken together, the data from the present study show that a variety of demographic factors are associated with rates of prenatal care, but they also suggest that rates of care are still substandard for a majority of Romanian women, whatever their sociodemographic features. Strengths and weaknesses A primary strength of our study is the robust design and large sample used in the original survey from which the present data were drawn. As a result, the latter provide a rare opportunity to assess the current state of prenatal care in Romania on a national scale. The major weakness of the study is that it was conducted using secondary data from an original study that was not designed to be a true experiment. So although demographic factors (e.g., maternal age and education) may appear to have a causal relationship with prenatal care, the cross-sectional design of the study does not allow for such inferences to be made. Instead, it identifies the extent of underutilisation and indicates several factors associated with it. Another limitation is that the extent of prenatal care was based on respondents’ recollection of their care. As a result, the number of visits may have shown a higher degree of variance than if case notes had been used instead. In order to minimise such variability to the greatest degree possible, only respondents who had given birth in the previous year were selected for analysis. A related limitation is that further variability may have been introduced by women who declined to participate or by women who 224
responded in a socially desirable manner by over-reporting care. Indeed, these sampling issues are present in most voluntary studies, but this one had a substantive advantage over many others because it used a large, national sample of data that were collected by trained and supervised investigators in a professional medical setting. Each of these factors alone would have increased the reliability of the data, and it is likely that combining all of the factors minimised potential problems. Differences in results in relation to other studies There are several differences between our study and previous research on the same topic. First, there are differences specific to the Romanian population. Namely, the present investigation brought to light that care utilisation was better today than it has been in the past8. Despite such improvement, though, mothers in Romania continue to receive substandard care. Another difference between previous studies and ours can be seen when rates of care utilisation are compared with those observed in other countries. Although many of the same demographic variables (e.g., education, age, etc.) are associated with prenatal care across the world, the present study differs in that it demonstrates that the magnitude of underutilisation in Romania is far higher than for its comparators16,17. The most striking difference between past studies and the present one pertains to the cost of care. Other investigators have shown that prenatal care tends to be best in countries where it is free or subsidised16, and in some cases inadequate care in these countries was encountered in as few as 4% of pregnancies18. Because prenatal services come at no direct cost to consumers in Romania, prenatal care in Romania could be considerably better than it is. Actually, Romania’s utilisation rates are among the lowest in the developed world. It may be that Romanian women, particularly those belonging to at-risk socio-demographic categories, have unseen costs of prenatal care by which their counterparts in other countries are not confronted. For instance, pregnant women residing in rural areas often have sizeable transportation costs in order to receive care from specialists. Our study was not designed to answer such questions. Future research should investigate this phenomenon.
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Relevance: Implications for health personnel and policymakers The Romanian Ministry of Health has taken steps over the last 25 years to improve health outcomes for both mothers and infants, yet the country’s infant mortality rate hovers near 9‰, its maternal mortality rate (by direct and indirect causes) is 0.11 per 1000 live births, the premature birth rate fluctuates around 10%, and the mean birth weight is 200 g less than the European average19,20. Most experts agree that prenatal care can be a foundation for a healthy pregnancy, and better care in Romania could play an important role in identifying at-risk pregnancies and improving health outcomes3,4. Our findings suggest that eliminating the cost of care alone is insufficient – although possibly still a necessary measure – for improving prenatal health care.They also demonstrate the need for policymakers and health personnel to target their interventions at individuals who are unlikely to seek available services. We observed that women living in rural areas utilised prenatal care services less than those in urban areas. By nature of their remote location (whether in Romania or elsewhere), women in rural areas often have limited access to obstetricians-gynaecologists. Targeted interventions designed specifically to reach rural women could increase prenatal care in this at-risk population. One such intervention might be to increase the number of practical specialists (i.e., midwives) in these areas. In developed European countries, midwives, rather than physicians, provide services for women who have low-risk pregnancies. In recent years, the Romanian government has opened educational programmes in midwifery, but it remains a fledgling occupation that must gain the trust of the population, form new professional and referral networks, and obtain full rights to care for pregnant women and new mothers. Such a practice in rural locations, where care is especially underutilised, would ease the burden on the available obstetricians who would thus be given more opportunities to care for women with higher-risk pregnancies. Unanswered questions and future research It is hoped that studies like this one will initiate a process in which targeted intervention is used to
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improve health outcomes for at-risk individuals in Romania and elsewhere. The priority for future research is to determine why care is underutilised in Romania. One possible approach to answering this question is to conduct qualitative research. Personal interviews provide unique insights that are missed by (necessarily impersonal) quantitative data, and care will be upgraded by giving additional insights to researchers, policymakers, clinicians, and healthcare personnel. It should again be stressed that the association we observed between demographic variables and prenatal care does not indicate a causal relationship. For this reason, future studies may also want to experimentally manipulate one or more of the socio-demographic variables that were associated with underutilisation in this study.
CONCLUSION
In spite of various attempts at remediation, prenatal care services in Romania are still underutilised by a large subset of the population. Although the problem has improved considerably in the last decade, many individuals in Romania remain at risk unnecessarily. A variety of demographic factors are associated with increased vulnerability to this risk, among them age, ethnicity, education, and location. As a result, available care goes unused by the most vulnerable members of the population, the young, the poor, the uneducated, and the ethnic minorities. AC K N OW L E D G E M E N T S
The cross-sectional survey ‘Assessment of the Current Situation of Breastfeeding and Nutrition Practices for Children from Birth to Two Years Old’ was made possible thanks to the financial support of several institutions, such as the Institute for Mother and Child Protection ‘Alfred Rusescu’, Bucharest, Romania; the Ministry of Health, Romania, and UNICEF Romania. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and the writing of the paper.
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REFERENCES
1. Macura M, MacDonald AL, Haug W, eds. The new demographic regime: Population challenges and policy responses. Vol. 5. New York/Geneva: United Nations Publications: 2005. Accessed 16 June 2013 from: http://www.unece. org.unecedev.colo.iway.ch/fileadmin/DAM/pau/_ docs/pau/PAU_2005_Publ_NDR.pdf 2. Akkerman D, Cleland L, Croft G, et al. Institute for Clinical Systems Improvement. Routine prenatal care: 2012. Accessed 9 July 2013 from: https://www.icsi. org/_asset/13n9y4/Prenatal.pdf 3. Carroli G, Rooney C,Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol 2001;15(Suppl. 1):1–42. 4. Panis C, Lillard L. Health inputs and child mortality: Malaysia. Health Econ 1994;13:455–89. 5. Badea M, Stativa E, Stephenson P, eds. Preventing maternal mortality in Romania. Bucharest, Romania: Ministry of Health, Institute for Mother and Child Care, UNICEF, WHO 1993. 6. Centrul National de Studii pentru Medicina Familiei. Ingrijiri prenatale in sarcina cu risc scazut. Ghid de practica pentru medicul de familie [Prenatal care in low-risk pregnancy. Practice guide to the family doctor]. Bucharest: InfoMedica 2005. Accessed 9 July 2013 from: http://www.ghidurimedicale.ro/download/ghid_ingrijiri_prenatale.pdf 7. Ministry of Health, The Order of 12/2004 updated by the Order of the Ministry of Health, No. 1982 of 5 December 2008.Accessed 13 June 2013 from: http://www. ghidconstructori.ro/snmf/legislatie/Legislatie_medicala/ OMSP%20nr%201982%20(fisa%20gravidei).pdf 8. Serbanescu F, Morris L, Marin M, eds. Reproductive health survey Romania, 1999: Final report. Bucharest, Romania: Romanian Association of Public Health and Health Management: 2001, Report No.: 99RRHS. 2001. Accessed 16 February 2013 from: http://stacks.cdc. gov/view/cdc/8249/ 9. Gheorghe DM, Nistorescu D, Stativa E, et al. Acompanierea Nasterii: Raport Final. Buzau: Alpha MDN 2011. 10. Ministerul Sanatatii, Banca Mondiala, UNFPA, USAID, UNICE. Studiul sanatatii reproducerii: Romania 2004 [Reproductive health survey: Romania 2004]. Buzau, Romania: Alpha MDN 2005. Accessed 16 February
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2013 from: http://www.unicef.org/romania/ro/ Studiul_Sanatati_Reproducerii.pdf Stativa E, Nanu M, eds. Nutritional status of pregnant women in Romania. Bucharest, Romania: Institute for Mother and Child Care ‘Alfred Rusescu’, Ministry of Health, UNICEF 2005. Accessed 10 July 2013 from: http:// www.unicef.org/romania/brochure_final_En.pdf Stativa E, Stoicescu S, eds. Evaluarea situa iei curente a al pt rii i a practicilor de nutri ie a copiilor de la na tere la 2 ani [Assessment of the current situation of breastfeeding and nutrition practices for children from birth to two years of age]. Bucharest, Romania: Institute for Mother and Child Care ‘Alfred Rusescu’, Ministry of Health, UNICEF 2011. Accessed 29 June 2013 from: https://portal-iomc. ro/c/document_library/get_file?uuid ⫽ 6f9e4d5fb5ec-42f7-a7c1–67fa44e2ab87 & groupId ⫽ 10138 Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994;84:1414–20. Alexander GR, Kotelchuck, M. Quantifying the adequacy of prenatal care: A comparison of indices. Public Health Rep 1996;111:408–19. IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp. Delvaux T, Buekens P, Godin I, Boutsen M. Barriers to prenatal care in Europe. Am J Prev Med 2001;21: 52–59. Delvaux T, Buekens P. Disparity in prenatal care in Europe. Eur J Obstet Gynecol Reprod Biol 1999;83:185–90. Buekens P, Kotelchuck M, Blondel B, et al. A comparison of prenatal care use in the United States and Europe. Am J Public Health 1993;83:31–6. Antal M, Ghenea G, Pirvu D. Miscarea naturala a populatiei. Bucharest, Romania: Ministry of Health, National Institute of Public Health, National Centre for Public Health Statistics and Informatics: Informative Bulletin, No. 10, 2012. Antal M, Ghenea G. Miscarea naturala a populatiei. Bucharest, Romania: Ministry of Health, National Institute of Public Health, National Centre for Public Health Statistics and Informatics: Informative Bulletin, No. 145, 2013.
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Characteristics and prenatal care utilisation of Romanian pregnant women Ecaterina Stativa*, Adrian V. Rus†, Nicolae Suciu*, Jacquelyn S. Pennings‡, Max E. Butterfield § , Reggies Wenyika† and Rebecca Webster † *The
Institute for Mother and Child Care ‘Alfred Rusescu’, Bucharest, Romania, † Behavioral Science Department, Southwestern Christian University, Oklahoma, USA, ‡Elite Research, LLC, Carrollton, Texas, USA, and §Psychology Department, Point Loma Nazarene University, California, USA
............................................................................................................................................................................................................
ABSTRACT
Objective To describe the degree to which Romanian women access free prenatal care services, and to describe the demographic profile of women who are at risk for underutilisation. Methods Secondary data (n ⫽ 914) were taken from a large, nationally representative sample of Romanian mothers and children (N ⫽ 2117). Kotelchuck’s Adequacy of Prenatal Care Utilisation Index was used to measure the adequacy of prenatal care. Results Seventy-eight percent of mothers underutilised prenatal care services. Those who did so to the greatest degree were likely to be young, members of an ethnic minority, poor, uneducated, and rural. Conversely, those who utilised care to the greatest degree were likely to be older, members of the ethnic majority, wealthy, educated, and city dwelling. Conclusion Despite the fact that many of the risk factors for underutilisation in this sample were similar to those found elsewhere in Europe and the developed world, these findings illustrate the worrisome magnitude of the problem in Romania, particularly among women with low levels of income and educational attainment. Future studies should examine factors that contribute to underutilisation, whether it corresponds to negative health outcomes, and whether targeted social interventions and outreach could help improve care.
K E Y WO R D S
Maternal health services; Maternal welfare; Obstetric care; Prenatal care; Romania
I N T RO D U C T I O N
The collapse of the Romanian communist regime in 1989 marked a new era for women’s health initiatives in Romania. Of particular note, health officials began implementing a comprehensive prenatal
care programme designed to increase positive health outcomes for infants and mothers1. The Ministry of Health adopted a standard of prenatal care practices similar to those prevailing in other developed countries2–4, and all women became eligible for a range of free prenatal care services, including risk assessments,
Correspondence: Adrian V. Rus, PhD, Southwestern Christian University, Behavioral Sciences Department, 7210 NW 39th Expressway, Bethany, OK 73008-0340, USA. Tel: ⫹ 1 405 789 7661, ext. 3450. Fax: ⫹ 1 405 495 0078. E-mail: [email protected]
© 2014 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2014.907399
Romanian prenatal care
medical examinations, laboratory tests and screenings, behavioural screenings, and prenatal counselling sessions5–7. However, more than a decade after reforms were initiated (in 2001), nearly nine in ten Romanian mothers across the social strata still did not receive adequate prenatal services8. The widespread lack of prenatal health care was particularly vexing in light of the fact that it came at no direct cost to consumers, and although initiatives to improve care have continued since that 2001 report, it was unclear whether pregnant women throughout the population were receiving insufficient prenatal attention9–11. As such, the primary objectives of the present study were twofold. The first objective was to access cross-sectional data from an existing dataset in order to determine current rates of care utilisation in Romania. The second objective was to explore whether demographic factors were associated with the quality of prenatal care. Ultimately, it was hoped that identification of such factors could be used in the future to aid public health efforts in Romania, as well as in other parts of the world. METHODS
Written consent was obtained from all participants before the study began and from the appropriate authorities. Specifically, the study was approved by the Institute for Mother and Child Care ‘Alfred Rusescu’ of Bucharest, Romania. This institution is under the authority of the Ministry of Health and its Board of Ethics and the Scientific Council approved the use of the data. The present study was also approved by the Institutional Review Board of Southwestern Christian University of Bethany, Oklahoma, United States. The data were drawn from a larger cross-sectional survey conducted during the second half of 2010, the Assessment of the Current Situation of Breastfeeding and Nutrition Practices for Children from Birth to Two Years Old12. This larger survey used a national family physician’s database and stratified, random sampling to select 2117 children aged 0–24 months. Respondents were selected with a sampling method that was designed primarily to control for any bias that could be caused by differences in population density (e.g., urban vs rural distinctions) across the country. The first step taken to ensure stratified random sampling that would be representative of all the macro-development regions of Romania was to randomly select two counties from
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each region for further sampling. From each of these counties, two urban localities and four or five villages were then randomly selected, as were two sectors of Bucharest (the largest city and capital of Romania) and one sector of the Bucuresti-Ilfov region that was not Bucharest.The random selection of these locations was made based on the lists of existing settlements in the Romanian Statistical Yearbook, 2009. In all, the resulting sample selected children from 16 Romanian counties, covering all eight macrodevelopment areas of the country. These children and their mothers were invited to the offices of their family physicians to answer a variety of health-related questions. There, 17 trained and experienced investigators collected the data using face-to-face interviews. The interviewers worked in groups of two to three individuals who verbally queried the mothers and then recorded the answers. To ensure consistency among researchers involved in data collection, all interview methods were thoroughly pre-tested (n ⫽ 80) before data collection was officially begun. The full data were collected over the course of four months between July 2010 and November 2010. To control for any interviewer-based errors and to ensure proper survey administration, the interview teams were supervised by research coordinators throughout the data collection process. From the larger sample, the mothers of children 12 months old and younger were asked an additional set of questions about their prenatal care. It was theorised that more recent care experiences would be more accurately remembered and reported, and so this measure was intended to maximise the accuracy with which respondents’ reported their care. More importantly, limiting the data to these women helped ensure that the data for the present study would reflect the most recent available trends in prenatal care utilisation. In all, these measures left a robust final sample of 914 respondents who were assessed in the present study. Seven socio-demographic variables of interest were used as categorical explanatory variables (EVs): age, ethnicity, marital status, education, location, socioeconomic status (SES), and parity. Age was recorded in years and divided into three categories: 15 to 19 years, 20 to 24 years, and 25 to 49 years. Ethnicity was coded as Romanian, Hungarian, or Roma. Marital status was coded as married or not married (including divorced, separated, widowed, or co-habiting). Education was coded into three categories based on years of school attended: gymnasium (0–8 years), high/technical school
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(9–12 years), and college (13 years or more). Location was coded as either urban or rural. SES was coded as low, medium, or high. To determine SES, participants were asked whether they owned 12 items: a stove, television, refrigerator, washing machine, mobile phone, flush toilet, central heating, private car, private housing, personal computer, video recorder, and vacation home. Participants who owned up to four goods or services were classified as low SES; those who owned at least five and up to eight were classified as medium SES; and those who owned at least nine were classified as high SES. Parity was coded as either no previous live birth or one or more previous live births. For each EV, the number of respondents concerned and the corresponding percentages are outlined in Table 1. The primary dependent measure was prenatal care utilisation, and it was assessed with the Adequacy of Prenatal Care Utilisation Index (APNCUI)13. The Table 1 Frequencies of respondents’ characteristics (N ⫽ 914). Characteristic Age 15 to 19 years 20 to 24 years 25 to 49 years Ethnicity Romanian Hungarian Roma Marital status Not married Married Education Gymnasium (0–8 years) High/Technical School (9–12 years) College (13 or more years) Location Urban Rural Socio-economic status Low Medium High Parity No previous live birth One or more previous live births ∗Due
n (%) ∗ 63 (7) 216 (24) 635 (70) 765 (84) 74 (8) 75 (8) 190 (21) 724 (79) 261 (29) 449 (49) 204 (22)
R E S U LT S 464 (51) 450 (49) 144 (16) 439 (48) 331 (36) 479 (52) 435 (48)
to rounding, the sum of the percentages in one case does not amount to 100%.
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APNCUI is one of several widely used prenatal care indices, and it was selected for use here because it is an effective measure of prenatal care that has already taken place14. The care received by each respondent was rated as one of four possible categories of utilisation: inadequate, inadequate plus, adequate, and adequate plus. It is important to note that the ‘inadequate plus’ care is typically referred to as ‘intermediate’ care; however, it is used to describe a level of care that is less than adequate, and so it is referred to here as inadequate plus to avoid confusion. According to the APNCUI, inadequate care required either initiation of care after the 4th month of pregnancy or less than 50% of recommended visits; inadequate plus care required 50 to 79% of the recommended number of visits; adequate care required 80 to 109% of the recommended number of visits; and adequate plus care required 110% or more of the recommended number of visits. These last three categories all required initiation of care by the 4th month of pregnancy. Finally, it should be noted that the APNCUI is designed to avoid incorrectly attributing underutilisation of care to preterm birth (10% of the present sample) by adjusting the required number of visits according to gestational age at delivery. For cases in which gestational age at delivery is unavailable, it is imputed based on birth weight and child sex. The present study followed these guidelines in order to measure care as accurately as possible. Once the APNCUI was calculated, a series of crosstabulations with Pearson’s chi-squared and Cramer’s V was conducted to examine the relationship between the APNCUI scores and the levels of each of the seven EVs. To determine specifically how each EV affected care, z-tests of the proportions were conducted to illustrate differences between the categorical levels of each EV. All analyses were conducted using SPSS version 19.015.
Table 1 shows the frequency of each EV subcategory in the present sample. Table 2 shows the frequency of each level of care in the present sample. Overall, only 22% of mothers received at least an adequate level of care. The chi-squared analysis had revealed that each EV had a significant relationship with prenatal care utilisation (all p values ⬍ .01), and Table 3 illustrates these relationships. Pregnant women who received inadequate care were likely to be young (⬍ 25 years old), Roma,
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educated (⬎ 8 years), and they had no previous children; no differences were found between levels of age, location, or SES for mothers who received adequate care (Table 3, column 3). Finally, it is important to note that the proportion of mothers in the adequate plus category was quite low across all of the demographic characteristics (2–8%).The only exception was that pregnant women with no previous children were more likely to receive adequate plus care than were those who already had children (Table 3, column 4).
Table 2 Frequencies of adequacy of prenatal care variables (N ⫽ 914). Adequacy of Prenatal Care Utilisation Index Inadequate Inadequate Plus Adequate Adequate Plus
n
(%)
390 322 147 55
43 35 16 6
unmarried, uneducated, residing in a rural area, low in SES, and they had other children (Table 3, column 1). In contrast, women who received inadequate plus care were most likely to be older (⬎ 25 years old), Romanian or Hungarian, married, well educated (⬎ 12 years), city dwelling, and high in SES (Table 3, column 2). In further contrast, those who received adequate care were most likely to be Romanian, intermediately
DISCUSSION
Findings and interpretation Some 78% of women in the present study did not receive adequate antenatal guidance. Each of the following demographic variables was associated
Table 3 Frequencies for respondents’ characteristics by Adequacy of Prenatal Care Utilisation Index (N ⫽ 914). Inadequate Inadequate ⫹ n Age 15 to 19 years 20 to 24 years 25 to 49 years Ethnicity Romanian Hungarian Roma Marital status Not married Married Education No school/Gymnasium High/Technical school College Location Urban Rural Socio-economic status Low Medium High Parity No previous live birth Previous live births
39 104 247
%
n
62a 48a 39b
13 66 243
41a 35a 71b
277 33 12
59a 38b
45 277
58a 4b 28c
64 166 92
156 234
34a 52b
82 204 104
57a 47b 31c
311 26 53 112 278 152 181 57
174 216
36a 50b
%
Adequate Adequate ⫹ n
%
n
21a 31a 38b
10 16a 30 14a 107 17a
1 16 38
36a 45a 16b
131 17a 11 15a 5 7b
46 4 5
24a 38b
21 11a 126 17b
12 43
25a 37b 45c
30 12a 77 17b 40 20b
15 25 15
192 130
41a 29b
84 18a 63 14a
40 137 145
28a 31a 44b
17 12a 68 16a 62 19a
179 143
37a 33a
88 18a 59 14b
%
Total n
2a 7a 6a
63 100 216 100 635 100
6a 5a 7a
765 100 74 100 75 100
6a 6a
190 100 724 100
6a 6a 7a
261 100 449 100 204 100
32 23
7a 5a
464 100 450 100
5 30 20
4a 7a 6a
144 100 439 100 331 100
38 17
8a 4b
c2
%
Cramer’s V
19.54∗
.103
30.23∗∗
.129
27.78∗∗
.174
46.40∗∗
.159
31.80∗∗
.187
34.59∗∗
.138
20.22∗∗
.149
479 100 435 100
∗p ⬍ 0.01; ∗∗p ⬍ 0.001. Proportions with different subscripts within the same block (e.g., age) and column are significantly
different (p ⬍ 0.05). Differences are tested within demographic item using z-test of proportions.
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with decreased levels of care: young age, low socioeconomic status, status as an ethnic minority (Roma), unmarried status, fewer years of education, rural location, and previous children. Even though rates of care seeking were associated with these variables, most women from across these social strata are not receiving attention that can be described as adequate. For example, 73% of college-educated women received a level below adequate care, as did exactly the same percentage of women with little education (0–8 years). Differences in care were admittedly observed between these groups: educated women were much more likely to fall in the ‘inadequate plus category’, whereas women with little education were much more likely to fall in the ‘inadequate category’. However, the same percentage of both groups received adequate or better attention. Taken together, the data from the present study show that a variety of demographic factors are associated with rates of prenatal care, but they also suggest that rates of care are still substandard for a majority of Romanian women, whatever their sociodemographic features. Strengths and weaknesses A primary strength of our study is the robust design and large sample used in the original survey from which the present data were drawn. As a result, the latter provide a rare opportunity to assess the current state of prenatal care in Romania on a national scale. The major weakness of the study is that it was conducted using secondary data from an original study that was not designed to be a true experiment. So although demographic factors (e.g., maternal age and education) may appear to have a causal relationship with prenatal care, the cross-sectional design of the study does not allow for such inferences to be made. Instead, it identifies the extent of underutilisation and indicates several factors associated with it. Another limitation is that the extent of prenatal care was based on respondents’ recollection of their care. As a result, the number of visits may have shown a higher degree of variance than if case notes had been used instead. In order to minimise such variability to the greatest degree possible, only respondents who had given birth in the previous year were selected for analysis. A related limitation is that further variability may have been introduced by women who declined to participate or by women who 224
responded in a socially desirable manner by over-reporting care. Indeed, these sampling issues are present in most voluntary studies, but this one had a substantive advantage over many others because it used a large, national sample of data that were collected by trained and supervised investigators in a professional medical setting. Each of these factors alone would have increased the reliability of the data, and it is likely that combining all of the factors minimised potential problems. Differences in results in relation to other studies There are several differences between our study and previous research on the same topic. First, there are differences specific to the Romanian population. Namely, the present investigation brought to light that care utilisation was better today than it has been in the past8. Despite such improvement, though, mothers in Romania continue to receive substandard care. Another difference between previous studies and ours can be seen when rates of care utilisation are compared with those observed in other countries. Although many of the same demographic variables (e.g., education, age, etc.) are associated with prenatal care across the world, the present study differs in that it demonstrates that the magnitude of underutilisation in Romania is far higher than for its comparators16,17. The most striking difference between past studies and the present one pertains to the cost of care. Other investigators have shown that prenatal care tends to be best in countries where it is free or subsidised16, and in some cases inadequate care in these countries was encountered in as few as 4% of pregnancies18. Because prenatal services come at no direct cost to consumers in Romania, prenatal care in Romania could be considerably better than it is. Actually, Romania’s utilisation rates are among the lowest in the developed world. It may be that Romanian women, particularly those belonging to at-risk socio-demographic categories, have unseen costs of prenatal care by which their counterparts in other countries are not confronted. For instance, pregnant women residing in rural areas often have sizeable transportation costs in order to receive care from specialists. Our study was not designed to answer such questions. Future research should investigate this phenomenon.
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Relevance: Implications for health personnel and policymakers The Romanian Ministry of Health has taken steps over the last 25 years to improve health outcomes for both mothers and infants, yet the country’s infant mortality rate hovers near 9‰, its maternal mortality rate (by direct and indirect causes) is 0.11 per 1000 live births, the premature birth rate fluctuates around 10%, and the mean birth weight is 200 g less than the European average19,20. Most experts agree that prenatal care can be a foundation for a healthy pregnancy, and better care in Romania could play an important role in identifying at-risk pregnancies and improving health outcomes3,4. Our findings suggest that eliminating the cost of care alone is insufficient – although possibly still a necessary measure – for improving prenatal health care.They also demonstrate the need for policymakers and health personnel to target their interventions at individuals who are unlikely to seek available services. We observed that women living in rural areas utilised prenatal care services less than those in urban areas. By nature of their remote location (whether in Romania or elsewhere), women in rural areas often have limited access to obstetricians-gynaecologists. Targeted interventions designed specifically to reach rural women could increase prenatal care in this at-risk population. One such intervention might be to increase the number of practical specialists (i.e., midwives) in these areas. In developed European countries, midwives, rather than physicians, provide services for women who have low-risk pregnancies. In recent years, the Romanian government has opened educational programmes in midwifery, but it remains a fledgling occupation that must gain the trust of the population, form new professional and referral networks, and obtain full rights to care for pregnant women and new mothers. Such a practice in rural locations, where care is especially underutilised, would ease the burden on the available obstetricians who would thus be given more opportunities to care for women with higher-risk pregnancies. Unanswered questions and future research It is hoped that studies like this one will initiate a process in which targeted intervention is used to
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improve health outcomes for at-risk individuals in Romania and elsewhere. The priority for future research is to determine why care is underutilised in Romania. One possible approach to answering this question is to conduct qualitative research. Personal interviews provide unique insights that are missed by (necessarily impersonal) quantitative data, and care will be upgraded by giving additional insights to researchers, policymakers, clinicians, and healthcare personnel. It should again be stressed that the association we observed between demographic variables and prenatal care does not indicate a causal relationship. For this reason, future studies may also want to experimentally manipulate one or more of the socio-demographic variables that were associated with underutilisation in this study.
CONCLUSION
In spite of various attempts at remediation, prenatal care services in Romania are still underutilised by a large subset of the population. Although the problem has improved considerably in the last decade, many individuals in Romania remain at risk unnecessarily. A variety of demographic factors are associated with increased vulnerability to this risk, among them age, ethnicity, education, and location. As a result, available care goes unused by the most vulnerable members of the population, the young, the poor, the uneducated, and the ethnic minorities. AC K N OW L E D G E M E N T S
The cross-sectional survey ‘Assessment of the Current Situation of Breastfeeding and Nutrition Practices for Children from Birth to Two Years Old’ was made possible thanks to the financial support of several institutions, such as the Institute for Mother and Child Protection ‘Alfred Rusescu’, Bucharest, Romania; the Ministry of Health, Romania, and UNICEF Romania. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and the writing of the paper.
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