Obstetrics & Gynecology:
Prenatal Care for Low‐Income Women Enrolled in a Managed‐Care Organization
GAZMARARIAN, JULIE A. MPH, PhD; ARRINGTON, TOYIA L. MPA; BAILEY, CATHY M. MS; SCHWARZ, KATY S. MSW; KOPLAN, JEFFREY P. MD, MPH
Prudential Center for Health Care Research, Atlanta, Georgia.
Address reprint requests to: Julie A. Gazmararian, MPH, PhD, Prudential Center for Health Care Research, 2859 Paces Ferry Road, Suite 820, Atlanta, GA 30339; E-mail: email@example.com
Received October 28, 1998. Received in revised form December 21, 1998. Accepted January 13, 1999.
Objective: To determine barriers to prenatal care among managed-care enrollees who receive Medicaid.
Methods: In-person interviews were conducted with women 13–45 years old who were members of the Prudential HealthCare Community Plan in Memphis, Tennessee. Interview data were linked to medical chart reviews for 200 women who were currently pregnant or had delivered a baby since enrollment in Prudential. Factors related to untimely entry to prenatal care and inadequate prenatal visits were examined.
Results: More than half of the respondents had either untimely entry to or inadequate prenatal care. Overall, 89% of respondents had favorable attitudes about prenatal care. Several system and personal factors were associated with receipt of early or adequate prenatal care. Multivariate analysis showed that one system and two personal factors remained significantly related to entry to prenatal care. Women who entered Prudential during pregnancy were 2.4 times more likely (95% CI 1.1, 5.0) to receive late care than women who 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 physical violence during pregnancy were 3.5 times more likely (95% CI 1.0, 12.0) to receive late care. Multivariate analysis with adequacy of prenatal care as the outcome showed several personal factors that increased odds of receiving inadequate prenatal care; however, only help from the infant's father was significantly related to adequacy of prenatal care. Women who did not have much help from the infant's father were 1.9 times more likely not to have adequate care (95% CI 1.0, 3.6).
Conclusion: Even when affordable care was available, many low-income women did not avail themselves of it. Although women knew the importance of prenatal care, there was a gap between attitudes and actually seeking appropriate care. System and personal factors need to be addressed to overcome barriers to prenatal care.
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.
1. Fink A, Yano EM, Goya D. Prenatal programs: What the literature reveals. Obstet Gynecol 1992;80:867–72.
2. Fiscella K. Does prenatal care improve birth outcomes? A critical review. Obstet Gynecol 1995;85:468–79.
3. Institute of Medicine. Preventing low birthweight. Washington, DC: National Academy Press, 1985.
4. Institute of Medicine. Prenatal care: Reaching mothers, reaching infants. Washington, DC: National Academy Press, 1988.
5. National Center for Health Statistics. Advance report of final natality statistics. Monthly vital statistics report, vol. 46, no. 2, Supplement, Hyattsville, MD: National Center for Health Statistics, 1996.
6. Cooney JP. What determines the start of prenatal care. Prenatal care, insurance, and education. Med Care 1985;23:986–97.
7. Goldenberg RL, Patterson ET, Freese MP. Maternal demographic, situational and psychosocial factors and their relationship to enrollment in prenatal care: A review of the literature. Women Health 1992;19:133–51.
8. Kiely JL, Mogan MD. Prenatal care. In: Wilcox LS, Marks JS. From data to action: Public health surveillance for women, infants, and children. CDC Monograph, Atlanta, Georgia: Centers for Disease Control and Prevention, 1994.
9. Lia-Hoagberg B, Rode P, Skovholt CJ, Oberg CN, Berg C, Mullett S, et al. Barriers and motivators to prenatal care among low-income women. Soc Sci Med 1990;30:487–95.
10. Greenberg RS. The impact of prenatal care in different social groups. Am J Obstet Gynecol 1983;145:797–801.
11. Oberg CN, Lia-Hoagberg B, Hodkinson E, Skovholt C, Vanman R. Prenatal care comparisons among privately insured, uninsured, and Medicaid-enrolled women. Pub Health Rep 1990;105:533–5.
12. Braveman P, Bennett T, Lewis C. Access to prenatal care following major Medicaid eligibility expansions. JAMA 1993;269:1285–9.
13. Haas JS, Udvarhelyi IS, Morris CN, Epstein AM. The effect of providing health coverage to poor uninsured pregnant women in Massachusetts. JAMA 1993;269:87–91.
14. Piper JM, Mitchel EF, Ray WA. Presumptive eligibility for pregnant Medicaid enrollees: Its effects on prenatal care and perinatal outcome. Am J Public Health 1994;84:1626–30.
15. Piper JM, Ray WA, Griffen MR. Effects of Medicaid eligibility expansion on prenatal care and pregnancy outcome in Tennessee. JAMA 1990;264:2219–23.
16. Ray WA, Gigante J, Mitchel EF Jr, Hickson GB. Perinatal outcomes following implementation of TennCare. JAMA 1998;279:314–6.
17. Augustyn M, Maiman LA. Psychological and sociological barriers to prenatal care. Womens Health Issues 1994;4:20–8.
18. Fisher MJ, Ewigman B, Campbell J, Benfer R, Furbee L, Zweig S. Cognitive factors influencing women to seek care during pregnancy. Fam Med 1991;23:443–6.
19. Perez-Woods RC. Barriers to the use of prenatal care: Critical analysis of the literature 1966–1987. J Perinatol 1990;10:420–34.
20. Schleuning D, Rice G, Rosenblatt RA. Addressing barriers to perinatal care: A case study of the Access to Maternity Care Committee in Washington State. Pub Health Rep 1991;106:47–52.
21. Mirvis DM, Chang CF, Hall CJ, Zaar GT, Applegate WB. TennCare—health system reform for Tennessee. JAMA 1995;274:1235–41.
22. Gazmararian JA, Parker RM, Baker DW. Reading skills and family planning knowledge and practices among low income enrollees. Obstet Gynecol 1999;93:239–44.
23. Sisk JE, Gorman SA, Reisinger AL, Glied SA, DuMouchel WH, Hynes MM. Evaluation of Medicaid managed care: Satisfaction, access and use. JAMA 1996;276:50–5.
24. Gazmararian JA, Schwarz KS, Amacker LB, Powell CL. Barriers to prenatal care among Medicaid managed care enrollees: Patient and provider perceptions. HMO Practice 1997;11:18–24.
25. 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.
26. U.S. Bureau of the Census. Statistical abstract of the United States: 1996. 100th ed. Washington, DC: U.S. Bureau of the Census, 1996.
27. Census of Housing 1980. Characteristics of housing units. Washington, DC: U.S. Department of Commerce, 1982:1(A).
28. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: Principles and quantitative methods. New York: Van Nostrand Reinhold, 1982.
29. SAS Institute Inc. SAS/STAT user's guide. Version 6, 4th ed, vol. 1. Cary, North Carolina: SAS Institute Inc, 1989.
30. Piper JM, Mitchel EF Jr, Ray WA. Expanded Medicaid coverage for pregnant women to 100 percent of the federal poverty level. Am J Prev Med 1994;10:97–102.
31. U.S. Department of Health and Human Services, Public Health Services. Healthy people 2000. National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office, 1991.
32. Dietz PM, Gazmararian JA, Goodwin MM, Bruce FC, Johnson CH, Rochat RW. Delayed entry into prenatal care: Effect of physical violence. Obstet Gynecol 1997;90:221–4.
33. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176–8.
34. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: Effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323–8.
35. Elam-Evans LD, Adams MM, Delaney KM, Wilson HG, Rochat RW, McCarthy BJ. Patterns of prenatal care initiation in Georgia, 1980–1992. Obstet Gynecol 1997;90:71–7.
This article has been cited 28 time(s).
Family Planning Perspectives
Many medicaid recipients in managed care plans do not take full advantage of available prenatal benefits
Family Planning Perspectives, 32(1):
Public Health Reports
Inadequate prenatal care and elevated blood lead levels among children born in providence, Rhode Island: A population-based study
Public Health Reports, 121(6):
Journal of the American Dietetic AssociationBarriers to the use of WIC servicesJournal of the American Dietetic Association
Journal of Midwifery & Womens HealthParticipation in prenatal care in the Paso del Norte border region: The influence of acculturationJournal of Midwifery & Womens Health
Nicotine & Tobacco ResearchPreventing postpartum smoking relapse among diverse low-income women: A randomized clinical trialNicotine & Tobacco Research
Journal of Womens Health & Gender-Based Medicine
The no-show rate in a high-risk obstetric clinic
Journal of Womens Health & Gender-Based Medicine, 9(8):
Obstetrics and Gynecology Clinics of North AmericaComponents and timing of prenatal careObstetrics and Gynecology Clinics of North America
Acta Obstetricia Et Gynecologica ScandinavicaPredictors of stillbirth among HIV-infected Tanzanian womenActa Obstetricia Et Gynecologica Scandinavica
Maternal and Child Health JournalThe Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto RicoMaternal and Child Health Journal
Jognn-Journal of Obstetric Gynecologic and Neonatal NursingBarriers to prenatal care for homeless pregnant womenJognn-Journal of Obstetric Gynecologic and Neonatal Nursing
Western Journal of Nursing ResearchHealth Behavior in Mexican Pregnant Women With a History of ViolenceWestern Journal of Nursing Research
Maternal and Child Nutrition
Mainstrearning nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes
Maternal and Child Nutrition, 4():
Womens Health Issues
Partner violence: Implications for health and community settings
Womens Health Issues, 11(2):
Nicotine & Tobacco ResearchFeasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokersNicotine & Tobacco Research
Violence Against WomenPrevalence, Types, and Pattern of Intimate Partner Violence Among Pregnant Women in Lima, PeruViolence Against Women
Ethnicity & Disease
Prenatal patients ' views of prenatal care services: A medical center-based assessment of knowledge and intent to use support services
Ethnicity & Disease, 14(1):
Maternal and Child Health JournalUse of home visit and developmental clinic services by high risk Mexican-American and white non-Hispanic infantsMaternal and Child Health Journal
ContraceptionA call to incorporate a reproductive justice agenda into reproductive health clinical practice and policyContraception
Journal of Nursing Scholarship
Barriers to utilization of prenatal care services in Turkey
Journal of Nursing Scholarship, 35(3):
Womens Health IssuesPrenatal care characteristics and African-American women's satisfaction with care in a managed care organizationWomens Health Issues
Violence Against WomenIntimate partner violence among pregnant Thai womenViolence Against Women
Journal of the American Dietetic Association
Evaluation of institutional support for breastfeeding among low-income women in the metropolitan New Orleans area
Journal of the American Dietetic Association, 102(1):
Public Health Nursing
Evaluating the social and economic impact of community-based prenatal care
Public Health Nursing, 24(4):
Womens Health Issues
How contraceptive use patterns differ by pregnancy intention: Implications for counseling
Womens Health Issues, 11(5):
American Journal of Public Health
Timing of insurance coverage and use of prenatal care among low-income women
American Journal of Public Health, 92(3):
European Journal of Obstetrics Gynecology and Reproductive BiologyUnexpected fetal death during pregnancy - a problem of unrecognized fetal disorders during antenatal care?European Journal of Obstetrics Gynecology and Reproductive Biology
Maternal and Child Health JournalRacial and ethnic disparities in Potentially Avoidable Delivery Complications among pregnant Medicaid beneficiaries in South CarolinaMaternal and Child Health Journal
Obstetrics & GynecologyDisparities in Pregnancy Outcomes According to Marital and Cohabitation StatusObstetrics & Gynecology
© 1999 The American College of Obstetricians and Gynecologists