Aust NZ J Obstet Gynaecol 1992; 3 2 4 306
The Demographic Characteristics of Early and Late Attenders for Antenatal Care Charles Essex’, MB, ChB, Anthea M. CounseIl*, MSc (Hons.) and David C . Geddis’, FRACP Research and Education Unit, Royal New Zealand Plunket Society (Inc), Dunedin North, New Zealand
EDITORIAL COMMENT: Thefindings in thk study will probably not surprise readers but the authors have established clinical markers for first antenatal attendance after I3 weeks’ gestation in New Zealand. Although the authors provide references (I-4)for an association bet ween late initial antenatal attendance and unfavourableperinatal results we urge them to analyze datafrom their own population and tell us what correlationsexist.
Summary: In the Royal New Zealand Plunket Society’s 1990-91 Cohort study, 581 of 4,286 women questioned (13.7%) had not initiated antenatal care until after the first trimester. These late attenders were more likely to be non-European or of high parity; 42.9% of Pacific Islander mothers and 28.9% of Maori mothers did not initiate antenatal care until after the first trimester. Late attenders were also more likely to be unmarried, of lower socioeconomic status, young or with lower educational attainment. The reason for delayed antenatal care needs to be investigated and mothers who are high parity and non-European need to be particularly targeted to encourage them to attend for antenatal care early.
The initial visit to the doctor or midwife in pregnancy is an important event. Physically, it allows medical and obstetric problems to be identified and treated. Guidance and information can be given concerning issues of health, nutrition and exercise, which may affect the fetus. Psychologically it is an initial acknowledgement of pregnancy and the life-changing events which will ensue (although the enormity of pregnancy and subsequent motherhood may take considerably longer to be fully realised). Although there is debate over the optimal time for beginning formal prenatal care, many reports suggest that prenatal care started after the second trimester is associated with low birth-weight and a higher neonatal mortality (1-4). Current thinking is that antenatal care should be started by the end of the first trimester ( 5 ) . In the United States late onset (or absent) prenatal care has been shown to be more likely to occur in blacks, Hispanics, teenagers and women over 40, those with lower education, or women of higher parity (6). These demographic findings have been supported by others in the UK and USA (4,7-10). Health service delivery systems in New Zealand and elsewhere have been accused of being culturally inappropriate or insensitive (11-13). The purpose of this 1. Regional Paediatrician 2. Research Officer. 3. Director. Address for correspondence: Dr Charles Essex, P.O. Box 6042, Dunedin North, New Zealand.
study was to examine the demographic and social profile of pregnant women in New Zealand who initiate their antenatal care after the first trimester of pregnancy.
METHODS AND SUBJECTS Data for the study were obtained from the Royal New Zealand Plunket Society’s 5-year longitudinal study of a birth cohort born in New Zealand during June, 1990 - June, 1991 of 4,286 children. The 4,286 babies enrolled represents 7 . 3 0 of the total livebirths for New Zealand during that year period. The demographics and methods of the study have already been described (14). The study was representative for New Zealand in terms of ethnicity, maternal age, marital status, parity, and geographical distribution. The parents were interviewed by Plunket nurses (in 2 districts by the Public Health nurses), and completed a questionnaire when the baby was approximately 6 weeks old. The parents gave signed informed consent to be included in the study, and the study was approved by the Plunket Society’s Independent Ethical Committee. Commencement of prenatal care was defined as how many weeks pregnant the mother was when she first saw her doctor or midwife for care related to this pregnancy. Late attenders for antenatal care were defined as those who began antenatal care after the first trimester. The definition of variables examined is given in table 1. The Elley-Irving scale (1983) for socioeconomic status (SES) is based on educational qualifications and salaries of various occupations (15). The scale ranges from 1 to 6 (1 being the highest). Father’s occupation was used
CHARLES ESSEXET AL
Table 1. Definition of Demographic Variables Examined
307
Socioeconomic The socioeconomic status was measured with the status Elley-Irving Scale, 1983, (7). Ethnic group 4 categories: European, Maori, Pacific Islander and other.
RESULTS There were 4,286 women recruited for the study. Fifty three questionnaires did not have the full data required and were thus omitted from the sample, reducing the numbers to 4,233. Overall 13.7% of mothers began antenatal care after the first trimester (at 13 weeks or later). Those attending late, differed significantly by maternal age, education, parity, marital status, SES and ethnic group (table 2). The late attenders tended to be younger, single, have less education, high parity, single, with lower SES, or were more likely to be Pacific Island or Maori than mothers who began antenatal care within the first trimester.
because 80% of the mothers gave their occupation at the time of the questionnaire was administered as fulltime parents. Unemployment was included due to the size of this group (over 400) and the common characteristics of those in this category. It should be noted that the ethnic group of the mother was not asked directly. It was assumed that where the child’s ethnic group was given as a single category, e.g. (Maori compared with Maori/European), the mother was of that ethnic group. This assumption was strengthened by comparison with other nationwide figures (14).
DISCUSSION The ethnic origin of late attenders has generated much interest and our study shows that being nonEuropean in New Zealand (and thus in an ethnic minority), is related to delayed initiation of care. Whilst only 6.9% of European mothers attend for antenatal care after the first trimester, 28.9% of Maori mothers and 42.9% of Pacific Island mothers attend later than this. Some authors have implied that antenatal services are culturally insensitive and inappropriate and are thus the reason why mothers of certain social, educational or ethnic group stay away (11-13), others have specifically asked nonattenders the reason why they did not initiate
Variable
Description
Parity
Number of children the mother has had ranging from 1 to more than 5.
Maternal education
Four categories of highest education achieved: less than 11 years, 11 years, 12 years 13 or more years. The mother’s age in years at the time the questionnaire was administered. 3 categories: married, defacto, or single.
Maternal age Marital status
Table 2. Late Attenders at Antenatal Care (After First Trimester) and Demographics
Variable
Number
Late attenders
% Late attenders
276 883 1,455 1,174 399
62 156 171 138 48
22.5% 17.7% 11.8% 11.8% 12.0
815 1,519 1,107 677
181 216 105 57
22.2% 14.2% 9.5% 8.4%
1,573 1,389 752 307 206
145 159 126 71 79
9.2% 11.5% 16.8% 23.1% 38.4%
2,943 690 586
280 140 158
9.5% 20.3% 27.0%
972 1,711 605 434
69 184 99 117
7.170 10.8% 16.4% 27.0%
2,676 507 238 803 4,233
185 146 102 148 581
6.9% 28.8% 42.9% 18.4% 13.7%
1. Maternal age (years)
< 20 20-24 25-29 30-2 35 + 2. Maternal education (yrs)
The Demographic Characteristics of Early and Late Attenders for Antenatal Care Charles Essex’, MB, ChB, Anthea M. CounseIl*, MSc (Hons.) and David C . Geddis’, FRACP Research and Education Unit, Royal New Zealand Plunket Society (Inc), Dunedin North, New Zealand
EDITORIAL COMMENT: Thefindings in thk study will probably not surprise readers but the authors have established clinical markers for first antenatal attendance after I3 weeks’ gestation in New Zealand. Although the authors provide references (I-4)for an association bet ween late initial antenatal attendance and unfavourableperinatal results we urge them to analyze datafrom their own population and tell us what correlationsexist.
Summary: In the Royal New Zealand Plunket Society’s 1990-91 Cohort study, 581 of 4,286 women questioned (13.7%) had not initiated antenatal care until after the first trimester. These late attenders were more likely to be non-European or of high parity; 42.9% of Pacific Islander mothers and 28.9% of Maori mothers did not initiate antenatal care until after the first trimester. Late attenders were also more likely to be unmarried, of lower socioeconomic status, young or with lower educational attainment. The reason for delayed antenatal care needs to be investigated and mothers who are high parity and non-European need to be particularly targeted to encourage them to attend for antenatal care early.
The initial visit to the doctor or midwife in pregnancy is an important event. Physically, it allows medical and obstetric problems to be identified and treated. Guidance and information can be given concerning issues of health, nutrition and exercise, which may affect the fetus. Psychologically it is an initial acknowledgement of pregnancy and the life-changing events which will ensue (although the enormity of pregnancy and subsequent motherhood may take considerably longer to be fully realised). Although there is debate over the optimal time for beginning formal prenatal care, many reports suggest that prenatal care started after the second trimester is associated with low birth-weight and a higher neonatal mortality (1-4). Current thinking is that antenatal care should be started by the end of the first trimester ( 5 ) . In the United States late onset (or absent) prenatal care has been shown to be more likely to occur in blacks, Hispanics, teenagers and women over 40, those with lower education, or women of higher parity (6). These demographic findings have been supported by others in the UK and USA (4,7-10). Health service delivery systems in New Zealand and elsewhere have been accused of being culturally inappropriate or insensitive (11-13). The purpose of this 1. Regional Paediatrician 2. Research Officer. 3. Director. Address for correspondence: Dr Charles Essex, P.O. Box 6042, Dunedin North, New Zealand.
study was to examine the demographic and social profile of pregnant women in New Zealand who initiate their antenatal care after the first trimester of pregnancy.
METHODS AND SUBJECTS Data for the study were obtained from the Royal New Zealand Plunket Society’s 5-year longitudinal study of a birth cohort born in New Zealand during June, 1990 - June, 1991 of 4,286 children. The 4,286 babies enrolled represents 7 . 3 0 of the total livebirths for New Zealand during that year period. The demographics and methods of the study have already been described (14). The study was representative for New Zealand in terms of ethnicity, maternal age, marital status, parity, and geographical distribution. The parents were interviewed by Plunket nurses (in 2 districts by the Public Health nurses), and completed a questionnaire when the baby was approximately 6 weeks old. The parents gave signed informed consent to be included in the study, and the study was approved by the Plunket Society’s Independent Ethical Committee. Commencement of prenatal care was defined as how many weeks pregnant the mother was when she first saw her doctor or midwife for care related to this pregnancy. Late attenders for antenatal care were defined as those who began antenatal care after the first trimester. The definition of variables examined is given in table 1. The Elley-Irving scale (1983) for socioeconomic status (SES) is based on educational qualifications and salaries of various occupations (15). The scale ranges from 1 to 6 (1 being the highest). Father’s occupation was used
CHARLES ESSEXET AL
Table 1. Definition of Demographic Variables Examined
307
Socioeconomic The socioeconomic status was measured with the status Elley-Irving Scale, 1983, (7). Ethnic group 4 categories: European, Maori, Pacific Islander and other.
RESULTS There were 4,286 women recruited for the study. Fifty three questionnaires did not have the full data required and were thus omitted from the sample, reducing the numbers to 4,233. Overall 13.7% of mothers began antenatal care after the first trimester (at 13 weeks or later). Those attending late, differed significantly by maternal age, education, parity, marital status, SES and ethnic group (table 2). The late attenders tended to be younger, single, have less education, high parity, single, with lower SES, or were more likely to be Pacific Island or Maori than mothers who began antenatal care within the first trimester.
because 80% of the mothers gave their occupation at the time of the questionnaire was administered as fulltime parents. Unemployment was included due to the size of this group (over 400) and the common characteristics of those in this category. It should be noted that the ethnic group of the mother was not asked directly. It was assumed that where the child’s ethnic group was given as a single category, e.g. (Maori compared with Maori/European), the mother was of that ethnic group. This assumption was strengthened by comparison with other nationwide figures (14).
DISCUSSION The ethnic origin of late attenders has generated much interest and our study shows that being nonEuropean in New Zealand (and thus in an ethnic minority), is related to delayed initiation of care. Whilst only 6.9% of European mothers attend for antenatal care after the first trimester, 28.9% of Maori mothers and 42.9% of Pacific Island mothers attend later than this. Some authors have implied that antenatal services are culturally insensitive and inappropriate and are thus the reason why mothers of certain social, educational or ethnic group stay away (11-13), others have specifically asked nonattenders the reason why they did not initiate
Variable
Description
Parity
Number of children the mother has had ranging from 1 to more than 5.
Maternal education
Four categories of highest education achieved: less than 11 years, 11 years, 12 years 13 or more years. The mother’s age in years at the time the questionnaire was administered. 3 categories: married, defacto, or single.
Maternal age Marital status
Table 2. Late Attenders at Antenatal Care (After First Trimester) and Demographics
Variable
Number
Late attenders
% Late attenders
276 883 1,455 1,174 399
62 156 171 138 48
22.5% 17.7% 11.8% 11.8% 12.0
815 1,519 1,107 677
181 216 105 57
22.2% 14.2% 9.5% 8.4%
1,573 1,389 752 307 206
145 159 126 71 79
9.2% 11.5% 16.8% 23.1% 38.4%
2,943 690 586
280 140 158
9.5% 20.3% 27.0%
972 1,711 605 434
69 184 99 117
7.170 10.8% 16.4% 27.0%
2,676 507 238 803 4,233
185 146 102 148 581
6.9% 28.8% 42.9% 18.4% 13.7%
1. Maternal age (years)
< 20 20-24 25-29 30-2 35 + 2. Maternal education (yrs)
