Prenatal Care Reaching Mothers, Reaching Infants (1988) / Chapter Skim
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3. Women's Perceptions of Barriers to Care
3. Women's Perceptions of Barriers to Care
Pages 88-114
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From page 88... ...
Not as well documented is the personal significance of various barriers to women themselves. Few reports on obstacles to prenatal care cite "consumer" views, and programs aimed at increasing participation in care are often designed without careful consideration of women's experiences in obtaining prenatal services.
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From page 89... ...
SEEECTION AND SYNTHESIS OF STUDIES To learn more about women's views concerning barriers to prenatal care, the Committee searched for studies of women who had obtained insufficient prenatal services and who had been asked about factors they felt had caused their delay in entering care. Only studies completed in the last 10 years preferably in the last S years—were reviewed.
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From page 90... ...
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From page 91... ...
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From page 92... ...
reveal that financial barriers— particularly inadequate or nonexistent insurance and limited personal funds- are the most important obstacles reported by women who received insufficient care. Transportation emerged as a substantial barrier in the checklist studies, although, as noted in Chapter 2, this barrier should probably be viewed primarily as a proxy for general financial stress rather than as a separate obstacle.
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From page 93... ...
Transportation Couldn't find a way to get to the appointment No transportation Transportation, not further specified 3. Prenatal care poorly valued or understood Already knew I was pregnant, so no reason to go Prenatal care is not necessary It's not important to seek prenatal care early I felt fine so there was no reason to come in earlier Prenatal care is necessary only if you're feeling sick I already knew what to do since I had been pregnant before I had no problem in previous pregnancies, so I didn't need to come Friends and relatives could answer my questions Too busy Too many other problems/things to do No room in my schedule 4.
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From page 94... ...
to know I was pregnant I didn't want to tell others I was pregnant 7. Limited provider availability No doctors, nurses, or midwives in the area My regular doctor did not provide prenatal care I was turned away from the first place I tried to get care No doctor would see me The doctor/clinic was not taking new patients Could not get an appointment at all Could not get an appointment earlier Couldn't find a doctor who took Medicaid patients 8.
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From page 96... ...
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From page 97... ...
Table 3.6 also reveals that other commonly reported barriers include transportation difficulties, inhospitable institutional practices, and a dislike or fear of prenatal services. These studies of women with no prenatal care at all are a rich source of data and descriptive material.
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From page 100... ...
Richwald et al.20 and Kaimuss et al.2i asked women with no care if they had actually tried to get care. Forty percent and 27 percent of the two samples, respectively, reported that they had not, which is consistent with the low value they report attaching to prenatal services and, perhaps, with their expectation of encountering difficulties in obtaining care.
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From page 101... ...
The South Carolina survey included 63 teenagers age 17 and younger who were asked about problems obtaining prenatal care. In clescending order, the four most common barriers cited were lack of money or insurance, lack of transportation, problems scheduling an appointment, and long waiting times in clinics.
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From page 102... ...
PROVIDER PERSPECTIVES Do providers of prenatal services see barriers to care in roughly the same way their clients do? In a 1987 survey by the American College of Obstetricians and Gynecologists, 2,400 of the college's members were asked to review and rate a list of 11 potential explanations for late registration in prenatal care.
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From page 103... ...
In general, however, virtually all respondents agreed that three barriers are the most significant financial problems, a low value attached to prenatal care, and transportation problems.25 Thus, there is notable agreement between clients and obstetricians. MUETIVARIATE ANALYSIS Multivariate analysis of factors associated with insufficient prenatal care can help bring some order to the voluminous data on obstacles to care.
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From page 106... ...
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From page 107... ...
to be significant in predicting insufficient care. The fact that the presence of Medicaid is also frequently found to be predictive of insufficient prenatal care underscores an important theme in Chapter 2: that although having Medicaid is undoubtedly better than having no insurance at all for the very poor women covered, the program has clearly been unable to draw low-income women into care efficiently and early in pregnancy.
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From page 108... ...
Mother unemployed 1.28 Less social support from 1.22 baby's father Johnson et al.; Unmarried 2.0 NA Outcome measure Massachusetts Higher parity 2.1 was adequacy of Younger 1.4 prenatal care Lower income 1.4-1.6 (Kessner) ; also Longer interval until NA trimester of woman "knew I was registration pregnant" Pregnancy unplanned 1.8 Dissatisfied with prenatal 1.2 Analysis controlled care for socioeconomic No health insurance 2.3 factors; race not during pregnancy found significant Used hospital clinic for 1.5 prenatal care Had no one to care for 1.7 other children Had never used [this]
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From page 109... ...
More transportation problems More problems with child care Later awareness of the pregnancy Higher parity Swink; Less education Oklahoma Money problems Less social support Longer interval since last physician visit Less importance given to seeing an M.D. as soon as pregnancy known Pregnancy outcome not believed to be significantly affected by prenatal care Kalmuss et al.; Younger New York Larger number of difficulties City reported in getting care Less education Negative attitude toward health care providers Absence of insurance Lower value attached to prenatal care Used drugs during pregnancy Fewer positive health-related behaviors during pregnancy 17.8 NA Only study that 5.4~.17 found Medicaid 2.94 0.71 '1.12 2.91 2.36 2.27 1.29 0.29 2.72 2.10 2.92 2.62 2.39 2.26 0.39 3.49 0.14 1.05 0.17 .27 NA .34 increases probability of sufficient care Continued
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From page 110... ...
More [sic] years in the community Financial loss in last year Complications in pregnancy Absence of private insurance Lower income Higher parity Care paid by Medicaid Care paid by self Pregnancy unplanned Younger Care paid by Medicaid Region in state Care paid by self Unplanned pregnancy Lower income Greater travel time to care NA .35 NA .36 NA .28 NA .13 NA .096 Outcome measure for all four state analyses summarized here was month care begun; analyses also done using ratio of actual to "prescribed" number of visits and Kessner index
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From page 111... ...
conception compared to only 8 percent of births to white women. The difference between the two race groups with respect to both the degree of unwanted childbearing and its consequences for obtaining adequate prenatal care is striking and seems to imply differing degrees of access to or use of effective birth control and/or resort to abortion when an unwanted pregnancy does occur.32
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From page 112... ...
Earlier experiences with prenatal care may also have been unsatisfying; perhaps the care was poorly explained, felt to be of uncertain value, or offered in an unacceptable manner. The multivariate analyses confirm many of the risk factors for insufficient prenatal care outlined in Chapter 1- poverty, being unmarried, under 20, higher parity, and less than a high school education.
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From page 113... ...
Finally, sets of factors found by multivariate analysis to predict insufficient prenatal care include many of the demographic risk factors discussed in Chapter 1 though not generally race plus unintended pregnancy, low value attached to prenatal care, poor links to the health care system generally, and negative attitudes toward providers.
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From page 114... ...
Prenatal Care: Medicaid Recipients and Uninsured Women Obtain Insufficient Care.
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