Timely prenatal care is a generally accepted hallmark of good practice and a measure of quality in clinical care and public health 1–4; however, many women, particularly minorities of lower socioeconomic status, do not receive adequate prenatal care. 3–9 Women who are least likely to seek adequate care are also most likely to have infants with poor outcomes. 3,10 For those at increased medical and social risk, prenatal care provides intervention and education to reduce or prevent risks and serves as a link to community resources. 2–4,8,10
Extensive research has tried to identify barriers to the use of prenatal care. Common areas examined include sociodemographic factors, system barriers, and cultural or personal barriers. 3,4 Sociodemographic factors have been the most well documented, with minority women of lower socioeconomic status most likely to receive inadequate prenatal care. Studies examining system barriers have generally focused on lack of money or insurance. 3,6,11 The recent expansion of Medicaid coverage and growing Medicaid managed-care population should have improved access, but studies have not shown increased use of prenatal care. 12–16 Many studies that explored cultural or personal characteristics of pregnant women who did not seek adequate care found that mothers' attitudes toward pregnancy, belief in the importance of care, and social support influence the seeking of adequate prenatal care. 4,6,17–20 Despite research examining barriers to prenatal care, very little is known about why some women in high-risk groups, such as minority women of lower socioeconomic status, receive adequate prenatal care and others do not. 7,8
In 1994, the state of Tennessee began to implement TennCare, which provided mandatory managed-care coverage for Medicaid and uninsured populations. 16,21 Prudential HealthCare Community Plan was one of the organizations that began covering TennCare enrollees in Memphis. Prudential, like many other managed-care organizations serving Medicaid enrollees, had limited experience providing care to underserved populations. During the first year of TennCare, Prudential noted that the rate of early (first-trimester) prenatal care was below 30% (based on chart review of a random sample of 100 deliveries). Thus, we were particularly interested in identifying the barriers to adequate prenatal care. Understanding the factors that limit participation in prenatal care is an important first step in determining how to increase access to such services.
To identify those barriers, we conducted in-person interviews with reproductive-aged women enrolled in the Prudential HealthCare Community Plan, providing a unique opportunity to collect detailed information from women who were underserved historically and were now entering a new health-care arrangement.
Materials and Methods
Details of selection of the study population are described elsewhere. 22 Women from 13–45 years of age who were enrolled in Prudential HealthCare Community Plan as of March 1, 1996, and who had a phone number or address were eligible (n = 1136). After excluding women who refused to participate (n = 204) and those who did not meet age and enrollment criteria (n = 216), 716 women were invited to participate and 506 interviews were completed between March 1996 and April 1997 (210 women did not attend their scheduled interviews), a response rate comparable to another study in a Medicaid population. 23 Because of our focus on women's use of prenatal care while a member of Prudential, we further limited our analysis to the 200 women who were currently pregnant (n = 33) or had delivered since enrollment in Prudential (n = 167).
Based on information collected during focus-group sessions, 24 previous research, and other surveys, we developed a questionnaire. The survey lasted 1 hour and covered use of the medical care system, use of community resources, reproductive health, attitudes about prenatal care, self description, social support, general health, educational information, and demographics.
Twenty trained interviewers (eight from the TennCare community) telephoned eligible women to schedule an interview in the respondent's home or other convenient location. Several measures were taken to ensure reliability between interviewers. All interviewers worked in pairs, the project coordinator (KS) periodically went with each interviewer and provided feedback, weekly meetings were held with the project coordinator and all interviewers, all surveys were edited weekly, and interviewers were given feedback. Respondents who completed the survey received an incentive ($25.00 grocery store certificate). Informed consent was signed as part of the questionnaire and confidentiality was assured to all participants. The study protocol was approved by the Prudential Center for Health Care Research institutional review board.
The dependent variables were measures of use of prenatal care from medical charts of respondents' most recent deliveries. We linked 98% (196 of 200 respondents) of the completed surveys to medical chart data. Six of the linked charts did not contain enough information to calculate the measures of use of prenatal care. We studied timeliness of initiation of prenatal care and adequacy of the number of prenatal visits. Care was considered timely (early) if it was initiated during the first trimester of pregnancy (0–14 weeks). Trimester of initiation was determined by the difference between date of the first prenatal care visit and estimated date of delivery. Adequacy of the number of visits was determined using the Kotelchuck Index, 25 which characterizes prenatal care use by two independent elements, adequacy of initiation of prenatal care and adequacy of received services after initiation. The expected number of visits was based on the ACOG prenatal care standards for uncomplicated pregnancies, adjusted for gestational age at initiation of care and delivery. 25 We categorized the number of visits as adequate if it met the Kotelchuck criteria for being adequate or intensive (more than 80% of expected visits); we called the number of visits inadequate if it met the Kotelchuck criteria for intermediate or inadequate. Respondents who did not receive any prenatal care (n = 2) were classified as having late or inadequate care.
The barriers examined were grouped according to the type of barrier: sociodemographic, system, or personal. Sociodemographic factors were age, race, marital status, education, employment, poverty level, and household crowding. This information was collected during the in-person interviews. Poverty status was determined by comparing the total number of persons living in the household and household income to U.S. Census poverty thresholds. 26 For example, a respondent living in a four-person household with income less than $16,036 would be considered living below poverty level. Women were classified as poor (below 100% of poverty level), near poor (100–199% of poverty level), or non-poor (above 200% of poverty level). Household crowding was assessed by the total number of persons per room. Women were classified as living in crowded conditions (more than 1.0 persons per room) or not living in crowded conditions (1.0 or fewer persons per room). 27
System barriers were data when women enrolled in Prudential, child care or transportation problems, travel time to clinic, not knowing where to go for appointments, inconvenient clinic hours, inability to get time off work, and worry about cost. Enrollment files from Prudential (verified by the Bureau of TennCare) were linked to survey and medical chart data to determine whether women enrolled in Prudential before conception or during their first, second, or third trimester of pregnancy. Women who enrolled before delivery, but were not enrolled at delivery, were classified as disenrolled before delivery. Data on all remaining system barriers were collected during in-person interviews.
Personal factors included attitude toward prenatal care, parity, pregnancy intent, fatigue, self-esteem, help from infant's father and family, physical violence during pregnancy, and smoking. Data on all personal factors were collected during the in-person interviews.
Questions about prenatal care attitudes were adapted from other studies and based on feedback provided from focus-group discussions. 24 Women were asked whether they either agreed or disagreed with 14 statements. One point was scored for each response that was positive toward prenatal care and the total score was summed. Women who responded positively to at least 80% of the questions (11 of 14) were classified as having a positive attitude toward prenatal care and those scoring less than 80% were categorized as having a negative attitude toward prenatal care.
Pregnancy intent was determined by the question, “Thinking back to just before you were pregnant, how did you feel about becoming pregnant?” (referring to the reference pregnancy). Intent was categorized as unwanted (the woman did not want pregnancy then or at any time in the future), mistimed (the woman wanted pregnancy later), or intended (the woman wanted pregnancy sooner or then).
Self-esteem was assessed by asking women how they felt about the statement, “All in all, I tend to feel that I am a failure.” Women were classified as agreeing or disagreeing with that statement. Violence during the reference pregnancy was determined by asking women whether during their pregnancy, they were “ever hit, slapped, kicked, or otherwise physically hurt by someone.”
Frequencies were compared between prenatal care use measures (initiation and adequacy) and demographic, system, and personal barriers to care. χ2 analyses were conducted to determine significant differences between prenatal care groups and characteristics of interest. 28 Multiple logistic regression analysis was conducted to determine the relationship between prenatal care use measures, adjusting for variables that were statistically significant (P < .05) in a bivariate analysis for both initiation and adequacy of prenatal care. Correlations were examined for variables included in logistic models, and if two variables were highly correlated, only one was retained in the model. All analyses were conducted using Statistical Analysis Software (SAS) package (SAS Institute, Cary, NC). 29 Missing values were infrequent (ranging from 0.3% for marital status to 2.9% for age) and excluded from analysis.
More than half (53.2%) of the respondents had untimely entry to prenatal care, and 51.3% had inadequate prenatal care (Table 1). Most women enrolled in the Prudential HealthCare Community Plan who completed in-person interviews were 25 years or older, black, single, high-school educated, employed (full or part-time), poor, and not living in crowded housing conditions. None of the sociodemographic factors were associated significantly with initiation or adequacy of prenatal care.
Most respondents enrolled in Prudential HealthCare Community Plan after they became pregnant and did not have problems with child care arrangements, transportation, knowing where to go for their visits, inconvenient clinic hours, getting time off work, or concerns about paying for care (Table 2). Time of enrollment and women's perception of inconvenient clinic hours were significantly related to initiation of care. For example, women who enrolled in Prudential HealthCare Community Plan after their first trimester (P = .032) and those who said that clinic hours were inconvenient (P = .024) were more likely to enter prenatal care late. Women who said they had child-care problems were more likely not to seek adequate care than women who said it was not a problem (P = .039).
Overall, women seemed to have positive attitudes toward prenatal care, and it was not related to initiation or adequacy of prenatal care (Table 3). Several personal factors were associated with initiation and adequacy of prenatal care (Table 4). Women who said they felt too tired (P = .015), had low self-esteem (felt like a failure) (P = .024), or experienced physical violence during pregnancy (P = .007) were more likely to receive late care. Women who had unwanted pregnancies (P = .002), felt too tired (P = .018), or received little or no help from the infant's father (P = .015) were more likely not to seek adequate care.
After adjusting for significant variables from the bivariate analysis, logistic regression analysis indicated that one system and two personal factors remained significantly related to initiation of prenatal care (Table 5). Women who entered Prudential during their pregnancies were 2.4 times more likely (95% confidence interval [CI] 1.1, 5.0) to receive late care than women who were enrolled before pregnancy. Women who felt too tired to go for care were 2.2 times more likely (95% CI 1.0, 4.9) to receive late care. Women who experienced of physical violence during pregnancy were 3.5 times more likely (95% CI 1.0, 12.0) to receive late care.
Logistic regression analysis with adequacy of prenatal care as the outcome found several personal factors that had increased odds of receiving inadequate prenatal care; however, only help from infant's father was significantly related to adequacy of prenatal care (Table 6). Women who did not have much help from the infant's father were 1.9 times less likely to seek adequate care (95% CI 1.0, 3.6).
Over half the respondents had inadequate prenatal care. The rates of use of prenatal care were lower in the present study than other studies in Tennessee, 14–16,30 national data, 3 and the year 2000 goal. 31 Part of that difference might be attributed to examination of medical charts versus self-reported data. More than 70% of women who completed interviews said that they received prenatal care in the first trimester, compared with approximately 50% based on medical charts.
Typical barriers, particularly demographic factors, were not related to entry to or adequacy of prenatal care in our predominantly lower socioeconomic status population. We did not find many other system or personal factors related to prenatal care that were suggested by others (eg, transportation, child-care problems, pregnancy intent, etc), particularly in our adjusted models. Women in our study seemed to have favorable attitudes toward prenatal care, which indicates that educational messages have been received; however, there was a gap between attitude about importance of care and whether they actually sought appropriate prenatal care.
Our finding that the date when women enrolled in the Prudential HealthCare Community Plan was related to untimely entry to prenatal care is intuitive, yet it highlights the need for critically examining the enrollment process. Managed care plans directly serving the TennCare population and the Bureau of TennCare need to ensure that the process is easy to follow and that new enrollees understand their coverage and how to get around in the new health-care environment. A compounding factor is that in the current system, an uninsured woman who does not normally qualify for TennCare can enroll temporarily and see a physician during her pregnancy. It is unknown what proportion of those women actually qualify for TennCare before becoming pregnant. Even if opportunities in the enrollment process were addressed, our data indicate that use of prenatal care services would still be inadequate, thus other efforts must be made.
The relationship between physical violence during pregnancy and initiation of prenatal care has been reported previously. 32–34 Routine screening for physical violence is increasingly suggested, but there is a need to reach women before they come into the health care system late in their pregnancy. The overall high rate of unintended pregnancy is another area of concern, and indicates a need for increased family planning efforts by managed-care organizations and other agencies in the community.
Data from our in-person interviews provided valuable information to assist in the delivery of quality care for women enrolled in the Prudential HealthCare Community Plan. By training women from the community to be interviewers, respondents were more comfortable answering the survey questions. Extensive efforts were made to contact women, even those who did not have a telephone. Our sample was larger than most other studies that collected in-person data from an under-served population; however, it might have been too small to detect some significant differences (eg, demographic factors).
There were several limitations to this study. We could not locate a large portion of the population. Once we located an enrolled woman, our screening and interview rates were fairly high. In addition to abstracting the medical records for women who participated (n = 196), we abstracted records for all other women who delivered between July 1995 and April 1997 (n = 492). Thus, we compared several key variables between participants and nonrespondents, indicating the respondents did not differ from nonrespondents with regard to trimester of entry to prenatal care, maternal age, preterm delivery, infant with low birth weight, and time of enrollment in Prudential. However, respondents were more likely to receive adequate care than nonrespondents (48.7% versus 36.9%, P = .007). Our respondents were also similar to TennCare data in terms of age and race characteristics. We only examined women's use of prenatal care services in a managed-care organization, thus we do not know whether their behavior was different before TennCare. We believe that prenatal care behavior is fairly consistent, based on previous research. 35
Data from this study provide valuable information about opportunities for improving delivery of care by managed-care organizations and the need for a comprehensive, multidisciplinary approach to prenatal care. A critical component of the present study was the organization of a consortium of approximately 40 groups representing community service agencies, providers, churches, hospitals, health departments, TennCare Bureau, and representatives from the TennCare community. The consortium has the potential to develop interventions for some of the factors identified in this study. Partnership between managed-care organizations that are beginning to deliver care to underserved populations and agencies that have historically worked with those populations are needed to ensure that appropriate care is received.
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