Barriers and motivators to prenatal care among low-income women

A randomized comparative-effectiveness study of two enhanced prenatal care models for low-income pregnant people: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE)

BACKGROUND

Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes.

METHODS

Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials.

CONCLUSIONS

This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04154423.

Disparities in early prenatal care and barriers to access among American Indian and white women in North Dakota

PURPOSE

American Indians/Alaska Natives (AI/AN) have received minimal attention in research on determinants of prenatal care access. We sought to gain an understanding of structural and sociocultural determinants of prenatal care access among AI/AN and White women in North Dakota (ND).

METHODS

Data were drawn from the 2017 to 2018 North Dakota Pregnancy Risk Assessment Monitoring System (n = 1,166). Late prenatal care was assessed with 2 variables: late prenatal care initiation (>13 weeks gestation) and "Did you get prenatal care as early in your pregnancy as you wanted?" (yes/no). Those not satisfied with timing of prenatal care initiation reported 12 prenatal care barriers (yes/no). Logistic regression estimated odds ratios and 95% confidence internals for late prenatal care among AI/AN and other race/ethnicity women compared to White women. Models included maternal sociodemographic, medical, and behavior factors. Chi-square was used to examine the prevalence of prenatal care barriers by race/ethnicity.

FINDINGS

AI/AN women had increased risk of late prenatal care initiation (OR: 1.93, 95%CI: 1.20, 3.09) and were more dissatisfied with timing of prenatal care initiation (OR: 1.73, 95% CI: 1.07, 2.78) compared to White women. AI/AN women reported higher prevalence for 8 of 12 (66%) barriers to care, including lack of transportation. Lack of health insurance was more prevalent among White women than AI/AN women (45%-8.5%; P<.01).

CONCLUSIONS

Socioeconomic barriers to prenatal care are more prevalent among AI/AN women. This may be a consequence of systematic separation of AI/AN populations from health care resources. Alternative prenatal care delivery methods and expansion of health insurance may improve prenatal care access in ND.

Barriers to Prenatal Care Among Food-Insufficient Women: Findings from the Pregnancy Risk Assessment Monitoring System

Background: This study examines the relationship among food insufficiency, adequacy of prenatal care, and barriers to prenatal care. Materials and Methods: Using data from the Pregnancy Risk Assessment Monitoring System (PRAMS), 2009-2016, negative binomial and logistic regression models were used to assess the association among food insufficiency during pregnancy, late onset of prenatal care, the number of prental care visits, as well as barriers to prenatal care. Results: Findings indicate that food insufficiency is associated with not initiating prenatal care during the first trimester and having fewer overall visits. In addition, food insufficiency is associated with more overall barriers to prenatal care, and this association operates through several specific barriers, including not having enough money, lacking transportation to get to the clinic or doctor's office, not being able to get time off work, not having a Medicaid card, having too many other things going on, and having no one to take care of children. Conclusion: Considering the adverse consequences of both food insufficiency and a lack of sufficient prenatal care for maternal and child health, study findings suggest a need to develop targeted interventions that expand access and remove barriers to prenatal care among food-insufficient women.

Timing of Prenatal Care Initiation in the Health Resources and Services Administration Health Center Program in 2017

BACKGROUND

Early prenatal care is vital for improving maternal health outcomes and health behaviors, but medically vulnerable and underserved populations are less likely to begin prenatal care in the first trimester. In 2017, the Health Center Program provided safety-net care to more than 27 million persons, including 573 026 prenatal patients, at approximately 12 000 sites across the United States and U.S. jurisdictions. As part of a mandatory reporting requirement, health centers tracked whether patients initiated prenatal care in their first trimester of pregnancy.

OBJECTIVE

To identify health center characteristics associated with the initiation of prenatal care in the first trimester, as well as actionable steps policymakers, providers, and health centers can take to promote early initiation of prenatal care.

DESIGN

Secondary analysis of cross-sectional data from the 2017 Uniform Data System.

SETTING

The United States and 8 U.S. jurisdictions.

PARTICIPANTS

Health center grantees with prenatal patients (n = 1281).

MEASUREMENTS

Multinomial logistic regression (adjusted for state or jurisdiction clustering) was used to identify health center characteristics associated with achievement of the Healthy People 2020 baseline (77.1%) and target (84.8%) for women receiving prenatal care in the first trimester (Maternal, Infant, and Child Health Objective 10.1).

RESULTS

Overall, 57.4% of health centers met the Healthy People 2020 baseline (mean, 78%; median, 81%), and 37.9% met the Healthy People 2020 target. Several characteristics were positively associated with meeting the baseline (larger proportion of prenatal patients aged 20 to 24 years) and target (more total patients, prenatal care by referral only, a larger proportion of prenatal patients aged 25 to 44 or ≥45 years, and a larger proportion of White or privately insured patients). Other characteristics were negatively associated with the baseline (location outside New England, location in a rural area, and a large proportion of prenatal patients aged <15 years) and target (more prenatal patients, location outside New England, provision of prenatal care to women living with HIV, and more uninsured patients or patients eligible for both Medicare and Medicaid).

LIMITATION

The data set is at the health center grantee level and does not contain information on timing or quality of follow-up prenatal care.

CONCLUSION

Most health centers met the Healthy People 2020 baseline, but opportunities for improvement remain and the Healthy People 2020 target is still a challenge for many health centers. Policymakers, providers, and health centers can learn from high-achieving centers to promote early initiation of prenatal care among medically vulnerable and underserved populations.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis

BACKGROUND

When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania.

METHODS

This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders' meetings held at ward level in which 450 people participated. Data were analysed using thematic approach.

RESULTS

Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers.

CONCLUSIONS

Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women's rights to access ANC services.

Pregnancy experiences of women in rural Romania: understanding ethnic and socioeconomic disparities

Women in rural Romania face significant health disadvantages. This qualitative pilot study describes the structural disadvantage experienced during pregnancy by women in rural Romania, focusing on the lived experiences of Roma women. We explore how women in rural communities experience pregnancy, their interactions with the healthcare system, and the role that ethnic and social factors play in pregnancy and childbearing. We conducted 42 semi-structured interviews with health and other professionals, seven narrative interviews with Roma and non-Roma women and a focus group with Roma women. Data were analysed using thematic analysis. We identified intersectional factors associated with women's pregnancy experiences: women perceiving pregnancy as both unplanned and wanted, joyful, and normal; women's and professionals' differing prenatal care perceptions; transport and cost related barriers to care; socioeconomic and ethnic discrimination; and facilitators to care such as social support, having a health mediator and having a doctor. Talking directly with professionals and Roma and non-Roma women helped us understand these many factors, how they are interconnected, and how we can work towards improving the pregnancy experiences of Roma women in rural Romania.

Inadequate prenatal care utilization among women with and without methadone-treated opioid use disorders in Taiwan

AIMS

The present study aims to investigate the utilization pattern of prenatal care and correlates for women with opioid use disorders (OUD) in Taiwan.

METHOD

Using the data linkage between the Methadone Maintenance Treatment (MMT) register with national health insurance, national birth notification system, and birth registration system, we identified 1712 pregnancies with 20 or more gestational weeks from women enrolled in the MMT (heroin-exposed: receiving no methadone treatment during pregnancy, n = 1053 by 882 women; methadone-treated: receiving methadone for at least one day during pregnancy, n = 659 by 574 women) and their 1:10 matched pregnancies from 17,060 women without substance use disorder in the period of 2004-2013. The generalized linear mixed models with negative binomial and logit distributions were performed to evaluate the relationship between individual sociodemographic, health, and addiction treatment characteristics with the number of prenatal visits and receiving prenatal care in the first trimester (i.e., early entry).

FINDINGS

Eighteen percent of pregnancies by women with OUD received no prenatal services and 21% had started prenatal care in the first trimester as compared with 1% and 46% in pregnancies by women without substance use disorders. For pregnancies by women with OUD, methadone treatment was not linked associated with prenatal care visits (adjusted relative risk [aRR] = 1.02; 95% = 0.92, 1.12). For methadone-treated pregnancies, treatment enrollment before pregnancy and spousal methadone treatment elevated prenatal visits by 8% and 18% (0.48 and 1.08 visits, respectively). Additionally, HIV infection (adjusted odds ratio [aOR] = 0.30, 95% CI = 0.10, 0.83) and prior delivery (aOR = 0.05, 95% CI = 0.01, 0.19) significantly reduced the odds of early entry into prenatal care.

CONCLUSION

Integrating addiction treatment programs with prenatal care is urgently needed to increase adequate prenatal care for pregnant women with OUD, especially the multiparous ones.

A tale of two pregnancies: A Critical Interpretive Synthesis of women's perceptions about delayed initiation of antenatal care

BACKGROUND

Delayed access to antenatal care in high income countries is associated with poor maternal, fetal and neonatal outcomes. The aim was to synthesise the diverse body of evidence around women's views of early antenatal care and barriers to attendance in such countries. Critical Interpretive Synthesis integrates the process of systematic review with the qualitative methods of meta-ethnography and grounded theory, with a focus on theory generation to inform policy, practice and future research.

METHODS

Database searches were conducted, supplemented with reference and citation tracking and website searching between February 2014 and April 2016. Qualitative data analysis methods were used to extract and summarise the key themes from each study. A taxonomy of constructs was created, with the synthesis developed to thread these together. Fifty-four papers were synthesised, including qualitative, quantitative, mixed method and systematic review, published between 1987 and 2016.

FINDINGS

Seventeen constructs around the core concept of 'acceptance of personal and public pregnancies' were produced. Acceptance of the 'personal' pregnancy considers the contribution of mindset in the recognition and acceptance of pregnancy, influenced by knowledge of pregnancy symptoms, pregnancy planning and desire. Acceptance of the 'public' pregnancy considers women's assessment of the social consequences of pregnancy, and the relevance and priority of antenatal care.

CONCLUSION

Critical Interpretive Synthesis offers a systematic yet creative approach to the synthesis of diverse evidence. The findings offer new perspectives on women's perceptions of early pregnancy and attendance for care, which may be used to facilitate timely antenatal provision for all pregnant women.

Patterns of Service Utilization Among Pregnant and Parenting African American Adolescents

This study explored factors associated with differential patterns of social and health service use among pregnant and parenting African American adolescents. One hundred seventy-seven young women between the ages of 14 and 22 took part in the study. Cluster analysis suggested three groups of users: frequent users, moderate users, and inconsistent users. These groups were distinct in terms of their frequency of service usage, perceptions of barriers to usage, and psychological and social functioning. Moderate users appeared to be healthier than either the frequent or inconsistent users, as indicated by their relatively higher levels of psychological functioning. In contrast, inconsistent users were distinguished by their high rates of sexual victimization, their low use of medical services, and their perceptions of many programmatic and personal barriers to usage. Suggestions for research and interventions that encompass the diverse needs of young African American women are made.

Anatomy of Good Prenatal Care: Perspectives of Low Income African-American Women on Barriers and Facilitators to Prenatal Care

BACKGROUND

Although early, consistent prenatal care (PNC) can be helpful in improving poor birth outcomes, rates of PNC use tend to be lower among African-American women compared to Whites. This study examines low-income African-American women's perspectives on barriers and facilitators to receiving PNC in an urban setting.

METHODS

We conducted six focus groups with 29 women and individual structured interviews with two women. Transcripts were coded to identify barriers and facilitators to obtaining PNC; codes were reviewed to identify emergent themes.

RESULTS

Barriers to obtaining PNC included structural barriers such as transportation and insurance, negative attitudes towards PNC, perceived poor quality of care, unintended pregnancy, and psychosocial stressors such as overall life stress and chaos. Facilitators of PNC included positive experiences such as trusting relationships with providers, respectful staff and providers, and social support.

CONCLUSIONS

Findings suggest important components in an ideal PNC model to engage low-income African-American women.

Trips to medical care among persons with disabilities: Evidence from the 2009 National Household Travel Survey

BACKGROUND

Persons with disabilities experience multiple barriers to obtaining necessary medical care. Problems with access to transportation and provider choice could lead to longer travel distances and longer travel times to medical appointments.

OBJECTIVE/HYPOTHESIS

1) Persons with disabilities travel further distances to receive necessary care, holding other variables constant. 2) Travel to medical appointments takes a longer amount of time for persons with disabilities, controlling for distance, mode of transportation and other factors. 3) Disability is the key factor influencing access to transportation options, holding other variables constant.

METHODS

The 2009 National Household Travel Survey (NHTS) is used to examine travel patterns of persons with disabilities as they access medical care. Logistic regressions are run on distance to medical appointments, time taken for travel to medical appointments, and access to private vehicle.

RESULTS

There is no difference in the distance traveled, but trips to medical care by persons with disabilities take longer amounts of time than trips taken by persons without disabilities, holding other variables constant. Access to private transportation is similar for both persons with and without disabilities.

CONCLUSIONS

Persons with disabilities experience longer travel times to receive medical care, despite traveling similar distances and having similar access to private vehicles.

Effectiveness of general preconception care accompanied by a recruitment approach: protocol of a community-based cohort study (the Healthy Pregnancy 4 All study)

INTRODUCTION

Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relative unfavourable perinatal outcomes. In response, a nationwide study Healthy Pregnancy 4 All (HP4ALL) has been initiated. One of the substudies within HP4ALL focuses on preconception care (PCC). PCC is an opportunity to detect and eliminate risk factors before conception to optimise health before organogenesis and placentation. The main objectives of the PCC substudy are (1) to assess the effectiveness of a recruitment strategy for the PCC health services and (2) to assess the effectiveness of individual PCC consultations.

METHODS/ANALYSIS

Prospective cohort study in neighbourhoods of 14 municipalities with perinatal mortality and morbidity rates exceeding the nation's average. The theoretical framework of the PCC substudy is based on Andersen's model of healthcare utilisation (a model that evaluates the utilisation of healthcare services from a sociological perspective). Women aged 18 up to and including 41 years are targeted for utilisation of the PCC health service by a four armed recruitment strategy. The PCC health service consists of an individual PCC consultation consisting of (1) initial risk assessment and risk management and (2) a follow-up consultation to assess adherence to the management plan. The primary outcomes regarding the effectiveness of consultations is behavioural change regarding folic acid supplementation, smoking cessation, cessation of alcohol consumption and illicit substance use. The primary outcome regarding the effectiveness of the recruitment strategy is the number of women successfully recruited and the outreach in terms of which population is reached in comparison to the approached population. Data collection consists of registration in the database of women that enrol for a visit to the individual PCC consultations (women successfully recruited), and preconsultation and postconsultation measurements among the included study population (by questionnaires, anthropometric measurements and biomarkers). Sample size calculation resulted in a sample size of n=839 women.

ETHICS AND DISSEMINATION

Approval for this study has been obtained from the Medical Ethical Committee of the Erasmus Medical Center of Rotterdam (MEC 2012-425). Results will be published and presented at international conferences.

Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case-control study

BACKGROUND

The reasons why women do not obtain prenatal care even when it is available and accessible are complex. Despite Canada's universally funded health care system, use of prenatal care varies widely across neighborhoods in Winnipeg, Manitoba, with the highest rates of inadequate prenatal care found in eight inner-city neighborhoods. The purpose of this study was to identify barriers, motivators and facilitators related to use of prenatal care among women living in these inner-city neighborhoods.

METHODS

We conducted a case-control study with 202 cases (inadequate prenatal care) and 406 controls (adequate prenatal care), frequency matched 1:2 by neighborhood. Women were recruited during their postpartum hospital stay, and were interviewed using a structured questionnaire. Stratified analyses of barriers and motivators associated with inadequate prenatal care were conducted, and the Mantel-Haenszel common odds ratio (OR) was reported when the results were homogeneous across neighborhoods. Chi square analysis was used to test for differences in proportions of cases and controls reporting facilitators that would have helped them get more prenatal care.

RESULTS

Of the 39 barriers assessed, 35 significantly increased the odds of inadequate prenatal care for inner-city women. Psychosocial issues that increased the likelihood of inadequate prenatal care included being under stress, having family problems, feeling depressed, "not thinking straight", and being worried that the baby would be apprehended by the child welfare agency. Structural barriers included not knowing where to get prenatal care, having a long wait to get an appointment, and having problems with child care or transportation. Attitudinal barriers included not planning or knowing about the pregnancy, thinking of having an abortion, and believing they did not need prenatal care. Of the 10 motivators assessed, four had a protective effect, such as the desire to learn how to protect one's health. Receiving incentives and getting help with transportation and child care would have facilitated women's attendance at prenatal care visits.

CONCLUSIONS

Several psychosocial, attitudinal, economic and structural barriers increased the likelihood of inadequate prenatal care for women living in socioeconomically disadvantaged neighborhoods. Removing barriers to prenatal care and capitalizing on factors that motivate and facilitate women to seek prenatal care despite the challenges of their personal circumstances may help improve use of prenatal care by inner-city women.

Understanding delayed access to antenatal care: a qualitative interview study

BACKGROUND

Delayed access to antenatal care ('late booking') has been linked to increased maternal and fetal mortality and morbidity. The aim of this qualitative study was to understand why some women are late to access antenatal care.

METHODS

27 women presenting after 19 completed weeks gestation for their first hospital booking appointment were interviewed, using a semi-structured format, in community and maternity hospital settings in South Yorkshire, United Kingdom. Interviews were transcribed verbatim and entered onto NVivo 8 software. An interdisciplinary, iterative, thematic analysis was undertaken.

RESULTS

The late booking women were diverse in terms of: age (15-37 years); parity (0-4); socioeconomic status; educational attainment and ethnicity. Three key themes relating to late booking were identified from our data: 1) 'not knowing': realisation (absence of classic symptoms, misinterpretation); belief (age, subfertility, using contraception, lay hindrance); 2) 'knowing': avoidance (ambivalence, fear, self-care); postponement (fear, location, not valuing care, self-care); and 3) 'delayed' (professional and system failures, knowledge/empowerment issues).

CONCLUSIONS

Whilst vulnerable groups are strongly represented in this study, women do not always fit a socio-cultural stereotype of a 'late booker'. We report a new taxonomy of more complex reasons for late antenatal booking than the prevalent concepts of denial, concealment and disadvantage. Explanatory sub-themes are also discussed, which relate to psychological, empowerment and socio-cultural factors. These include poor reproductive health knowledge and delayed recognition of pregnancy, the influence of a pregnancy 'mindset' and previous pregnancy experience, and the perceived value of antenatal care. The study also highlights deficiencies in early pregnancy diagnosis and service organisation. These issues should be considered by practitioners and service commissioners in order to promote timely antenatal care for all women.

Socioeconomic status affects oral and manual exploration across the first year

Oral and manual exploration are part of the foundation of problem solving and cognition in infancy. How these develop in an at-risk population, infants in poverty, is unknown. The current study tested exploratory behaviors longitudinally at 6, 9, and 12 months in infants from high- and low-socioeconomic (SES) families. Oral exploration consisted of passive and active mouthing and looks after active mouthing. Manual exploration consisted of frequency of fingering, rotating, and transferring the object. High-SES infants replicated the trajectory previously reported in the literature, showing a decrease in mouthing and fingering and an increase in rotating and transferring (e.g., Palmer, 1989). In contrast, low-SES infants showed no change in any of the manual exploratory behaviors over the first year, thus demonstrating reduced overall levels of exploration as well as a different developmental trajectory. Results are discussed in terms of attention, potential physiological mechanisms, and implications for later problem solving.

Is obesity an independent barrier to obtaining prenatal care?

OBJECTIVE

Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC.

STUDY DESIGN

We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m(2)), normal weight (18.5 to 24.9 kg/m(2)), overweight (25.0 to 29.9 kg/m(2)), and obese (≥30 kg/m(2)). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using χ(2) and nonparametric analyses.

RESULTS

Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p = 0.41).

CONCLUSION

In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care.

Predictors of inadequate prenatal care in methamphetamine-using mothers in New Zealand and the United States

This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socioeconomic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.

Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the Millennium Cohort Study

OBJECTIVE

To explore the maternal demographic factors associated with operative births (instrumental vaginal births or caesarean section), after adjustment for health, interpersonal, pregnancy, labour and infant covariates.

DESIGN

Nationally representative cohort study.

SETTING

Women giving birth in the UK, during the period 2000-2002.

SAMPLE

A total of 18,239 mother-infant pairs.

METHODS

Multinomial logistic regression models were estimated to explore the relationship between demographic characteristics and mode of birth, stratified by parity.

MAIN OUTCOME MEASURES

Self-reported mode of birth, defined as unassisted vaginal birth, instrumental vaginal birth, emergency caesarean section and planned caesarean section.

RESULTS

For primiparous women, operative births rose steeply with increasing maternal age. Women from lower occupational status households were at an increased risk of planned caesarean section. Mode of birth differed significantly by ethnicity. For multiparous women, a younger age at first birth was protective of a later caesarean section or instrumental vaginal birth at the cohort birth. Women with qualifications normally taken at the age 18 years were at an increased risk of planned caesarean section compared with women with degree-level qualifications. Mode of birth differed significantly by ethnicity, and non-UK born women were at an increased risk of emergency caesarean section.

CONCLUSIONS

The sociodemographic characteristics of UK women independently predict mode of birth. Further research is needed to establish to what extent sociodemographic differences in mode of birth are a reflection of the attitudes and behaviours of women, or health professionals, and are therefore amenable to change.

Effects of prenatal care on child health at age 5

The broad goal of contemporary prenatal care is to promote the health of the mother, child, and family through the pregnancy, delivery, and the child's development. Although the vast majority of mothers giving birth in developed countries receive prenatal care, past research has not found compelling evidence that early or adequate prenatal care has favorable effects on birth outcomes. It is possible that prenatal care confers health benefits to the child that do not become apparent until after the perinatal period. Using data from a national urban birth cohort study in the US, we estimate the effects of prenatal care on four markers of child health at age 5-maternal-reported health status, asthma diagnosis, overweight, and height. Prenatal care, defined a number of different ways, does not appear to have any effect on the outcomes examined. The findings are robust and suggest that routine health care encounters during the prenatal period could potentially be used more effectively to enhance children's health trajectories. However, future research is needed to explore the effects of prenatal care on additional child health and developmental outcomes as well as the effects of preconceptional and maternal lifetime healthcare on child health.

Prenatal care: touching the future

The provision of preconception and prenatal care is a critical and time-honored role for family physicians. It could even be termed the first preventive care a human being receives. It has been suggested by some studies that, because of the continuity of care that is considered a cornerstone of family practice, family physicians provide prenatal care that may improve birth outcome. Although prenatal care is acknowledged as important for a healthy pregnancy and delivery, there is debate regarding the true efficacy of prenatal care.

Understanding prenatal health care for American Indian women in a Northern Plains tribe

Early and regular prenatal care appointments are imperative for the health of both the mother and baby to help prevent complications associated with pregnancy and birth. American Indian women are especially at risk for health disparities related to pregnancy and lack of prenatal health care. Previous research has outlined a basic understanding of the reasons for lack of prenatal care for women in general; however, little is known about care received by pregnant women at Indian Health Service hospitals. Qualitative interviews were carried out with 58 women to better understand the prenatal health experiences of American Indian women from one tribe in the Northern Plains. Several themes related to American Indian women's prenatal health care experiences were noted, including communication barriers with physicians, institutional barriers such as lack of continuity of care, and sociodemographic barriers. Solutions to these barriers, such as a nurse midwife program, are discussed.

Devolution's policy impact on non-emergency medical transportation in State Children's Health Insurance Programs

Proponents of devolution often maintain that the transfer of power and authority of programs enables local officials to craft policy solutions that better align with the needs of their constituents. This article provides one of the first empirical evaluations of this assumption as it relates to non-emergency medical transportation (NEMT) in the State Children's Health Insurance Program (SCHIP). NEMT programs meet a critical need in the areas in which they serve, directly targeting this single key access barrier to care. Yet states have great latitude in making such services available. The authors utilize data from 32 states to provide a preliminary assessment of devolution's consequences and policy impact on transportation-related access to care. Their findings provide mixed evidence on devolution's impact on policy outcomes. Proponents of devolution can find solace in the fact that several states have gone beyond federally mandated minimum requirements to offer innovative programs to remove transportation barriers to care. Detractors of devolution will find continued pause on several key issues, as a number of states do not offer NEMT to their SCHIP populations while cutting services and leaving over $7 billion in federal matching funding unspent.

A systematic review and meta-analysis of racial disparities in prenatal care in California: How much? Does insurance matter?

This meta-analysis compares California to 13 states with regard to adequacy of prenatal care in the context of the major Medicaid expansion. It shows a reduction in prenatal care inadequacy after 1992, especially in California. It also shows persistent racial ethnic disparities. By examining how California differed from other states, this study provides not only benchmarks for attaining the Healthy People 2010 goal of 90% adequacy but also possible strategies for achieving this goal. Attaining the Healthy People 2010 objective for prenatal care for California as a whole will require further efforts to understand and address racial/ethnic and insurance-related inequalities.

Effects of prenatal care on maternal postpartum behaviors

Most research on the effectiveness of prenatal care has focused on birth outcomes and has found small or no effects. It is possible, however, that prenatal care is "too little too late" to improve pregnancy outcomes in the aggregate, but that it increases the use of pediatric health care or improves maternal health-related parenting practices and, ultimately, child health. We use data from the Fragile Families and Child Wellbeing birth cohort study that have been augmented with hospital medical record data to estimate effects of prenatal care timing on pediatric health care utilization and health-related parenting behaviors during the first year of the child's life. We focus on maternal postpartum smoking, preventive health care visits for the child, and breastfeeding. We use a multi-pronged approach to address the potential endogeneity of the timing of prenatal care. We find that first trimester prenatal care appears to decrease maternal postpartum smoking by about 5 percentage points and increase the likelihood of 4 or more well-baby visits by about 1 percentage point, and that it may also have a positive effect on breastfeeding. These findings suggest that there are benefits to standard prenatal care that are generally not considered in evaluations of prenatal care programs and interventions.

Infant care practices in rural China and their relation to prenatal care utilisation

Studies describing postpartum childcare practices and the influence of prenatal care on infant care outcomes in rural China are scarce. This study looked at data for 1479 women who had given birth during the preceding 2 years (median age of the child was 8 months). Data were available from a Knowledge, Attitude and Perception cross-sectional survey collected from 2001 to 2003, after a prenatal care intervention in Anhui County, China, with a response rate of 97%. Prenatal care utilisation was categorised using the Adequacy of Prenatal Care Utilisation index. Logistic regression was used to study the association between prenatal care utilisation and infant care practices. Mothers' uptake of breastfeeding, introduction of milk formula, cereal/porridge, meat and uptake of any immunisation were found to be in accordance with national recommendations. Intermediate prenatal care uptake was positively associated with never breastfeeding and early introduction of cereal/porridge. Inadequate care was positively associated with never breastfeeding, early introduction of milk formula and cereal/porridge, and early start of work after delivery. Initiation to prenatal care after the third month was positively associated with early introduction of milk formula and cereal/porridge. Having no prenatal care was positively associated with never breastfeeding and early introduction of milk formula. Mothers' uptake of infant care practices in this population was largely in accordance with national recommendations. Women with less than adequate utilisation of prenatal care and those who had initiated prenatal care late were less likely to follow recommendations on infant care.

Women's perceptions of access to prenatal care in the United States: a literature review

Women report many barriers to accessing prenatal care. This article reviews the literature from 1990 to the present on women's perceptions of access to prenatal care within the United States. Barriers can be classified into societal, maternal, and structural dimensions. Women may not be motivated to seek care, especially for unintended pregnancies. Societal and maternal reasons cited for poor motivation include a fear of medical procedures or disclosing the pregnancy to others, depression, and a belief that prenatal care is unnecessary. Structural barriers include long wait times, the location and hours of the clinic, language and attitude of the clinic staff and provider, the cost of services, and a lack of child-friendly facilities. Knowledge of women's views of access can help in development of policies to decrease barriers. Structural barriers could be reduced through changes in clinic policy and prenatal care format, and the creation of child-friendly waiting and examination rooms. Maternal and societal barriers can be addressed through community education. A focus in future research on facilitators of access can assist in creating open pathways to perinatal care for all women.

'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries

BACKGROUND

In high-resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated.

OBJECTIVES

To identify the factors affecting access to antenatal care for marginalised pregnant women living in developed countries.

SEARCH STRATEGY

We included qualitative studies from developed countries published in English language journals (1980-2007).

SELECTION CRITERIA

Qualitative studies exploring the views of marginalised women living in developed countries who either failed to attend for any antenatal care or did so late or irregularly.

DATA COLLECTION AND ANALYSIS

Eight studies fulfilled the selection criteria and were synthesised in accord with the techniques derived from meta-ethnography.

MAIN RESULTS

Initial access is influenced by late pregnancy recognition and subsequent denial or acceptance. Continuing access appears to depend on a strategy of weighing up and balancing out of the perceived gains and losses. Personal resources in terms of time, money and social support are considered alongside service provision issues including the perceived quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect.

CONCLUSIONS

A nonthreatening, nonjudgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake.

Drug use and limited prenatal care: an examination of responsible barriers

OBJECTIVE

The purpose of this study was to determine sociodemographic, psychosocial, and health belief factors that explain the association between maternal drug use and little or no prenatal care.

STUDY DESIGN

A cohort of 812 low-income women who delivered at Johns Hopkins Hospital were administered a postpartum survey. Drug use was determined by self-report, medical record, and toxicologic screens. Medical records were abstracted to determine little or no prenatal care, as defined by </= 1 visit.

RESULTS

Adjustments for sociodemographic characteristics and cocaine and opiate use were predictive of little or no prenatal care. The effect of cocaine was explained by psychosocial and health belief factors: external locus of control, fear of being reported to police, and disbelief in the efficacy of care. Opiate use remained strongly related to little or no care in fully adjusted models (odds ratio, 3.16; P < .001).

CONCLUSION

Different outreach and education strategies may be necessary to enroll cocaine- vs opiate-using women into prenatal care.

Initiation of and barriers to prenatal care use among low-income women in San Antonio, Texas

Healthy People 2010 goals set a target of 90% of mothers starting prenatal care in the first trimester of pregnancy. While there are questions about the value of prenatal care (PNC), there is much observational evidence of the benefits of PNC including reduction in maternal, fetal, perinatal, and infant deaths. The objective of this study was to understand barriers to PNC as well as factors that impact early initiation of care among low-income women in San Antonio, Texas. A survey study was conducted among low-income women seeking care at selected public health clinics in San Antonio. Interviews were conducted with 444 women. Study results show that women with social barriers, those who were less educated, who were living alone (i.e. without an adult partner or spouse), or who had not planned their pregnancies were more likely to initiate PNC late in their pregnancies. It was also observed that women who enrolled in the WIC program were more likely to initiate PNC early in their pregnancies. Women who initiated PNC late in pregnancy had the highest odds of reporting service-related barriers to receiving care. However, financial and personal barriers created no significant obstacles to women initiating PNC. The majority of women in this study reported that they were aware of the importance of PNC, knew where to go for care during pregnancy, and were able to pay for care through financial assistance, yet some did not initiate early prenatal care. This clearly establishes that the decision making process regarding PNC is complex. It is important that programs consider the complexity of the decision-making process and the priorities women set during pregnancy in planning interventions, particularly those that target low-income women. This could increase the likelihood that these women will seek PNC early in their pregnancies.

Validation of a screening tool to identify the nutritionally at-risk pregnancy

OBJECTIVE

To assess the efficacy of a screening tool to be used by nurses to determine which economically disadvantaged pregnant women are most likely to benefit from a dietitian's intensive intervention.

METHODS

The 26-variable screening tool was used by 53 nurses in 17 Montreal primary care facilities at first contact with 300 subjects who were eligible for prenatal programs for low-income women. Among these, 259 subjects were subsequently interviewed by a Montreal Diet Dispensary (MDD) dietitian using the Higgins Method, established as the gold standard for the detection of a nutritionally at-risk pregnancy. Comparisons of the results obtained by dietitians using the Higgins Method with scores obtained by nurses using the screening tool to determine risk levels and individual variables were analyzed using the Pearson correlation coefficient, receiver operating characteristic (ROC) curves, and predictive indices such as sensitivity, specificity, and predictive values.

RESULTS

Because of low agreement between the findings of MDD dietitians and nurses using the screening tool, 10 variables were excluded. The resulting 16-variable tool showed a correlation coefficient of 0.70. The ROC cut-off for this simplified tool was 8, meaning that a woman would be considered at nutritional risk if her score was 8 or more. This score optimized sensitivity (85%) with rather low specificity (50%), but retained a positive predictive value of 87% and a negative predictive value of 55%.

CONCLUSION

Revisions of the screening tool to identify nutritionally at-risk pregnant women led to the development of a simplified screening tool with an acceptable measure of nutritional risk in pregnancy. Hence, the use of this tool by any health professional will identify the majority of the nutritionally at-risk pregnant women most likely to benefit from a dietitian's intensive intervention.

Social inequalities in use of prenatal care in Manitoba

OBJECTIVE

Analysis of regional variations in use of prenatal care to identify individual-level and neighbourhood-level determinants of inadequate prenatal care among women giving birth in the province of Manitoba.

METHODS

Data were obtained from Manitoba Health administrative databases and the 1996 Canadian Census. An index of prenatal care use was calculated for each singleton live birth from 1991 to 2000 (N = 149,291). Births were geocoded into 498 geographic districts, and a spatial analysis was conducted, consisting of data visualization, spatial clustering, and data modelling using Poisson regression.

RESULTS

We found wide variation in rates of inadequate prenatal care across geographic areas, ranging from 1.1% to 21.5%. Higher rates of inadequate care were found in the inner-city of Winnipeg and in northern Manitoba. After adjusting for individual characteristics, the highest rates of inadequate prenatal care were among women living in neighbourhoods with the lowest average family income, the highest proportion of the population who were unemployed, the highest rates of recent immigrants, the highest percentage of the population reporting Aboriginal status, the highest percentage of single parent families, the highest percentage of the population with fewer than nine years of education, and the highest rates of women who smoked during pregnancy.

CONCLUSION

Social inequalities exist in the use of prenatal care among Manitoba women, despite there being a universally funded health care system. Regional disparities in rates of inadequate prenatal care emphasize the need for further research to determine specific risk factors for inadequate prenatal care in socioeconomically disadvantaged neighbourhoods, followed by provision of effective targeted services.

Association of preconceptional health care utilization and early initiation of prenatal care

OBJECTIVE

To assess whether women having preconceptional health care utilization were more likely to have early initiation of prenatal care than were women not having preconceptional health care utilization.

STUDY DESIGN

In this cohort study, data were collected prospectively from a population-based Perinatal Health Care Surveillance System in China. The analysis included 195 796 women who delivered single live births in 13 cities/counties during 1997 to 2000. Mantel-Haenszel test was employed to calculate risk ratios and 95% confidence intervals (CI). Multivariate logistic regression was conducted to assess the association between preconceptional health care utilization and early initiation of prenatal care after controlling for maternal residence, age at delivery, educational attainment, occupation, parity, preconceptional medical disorders, and high-risk medical experiences during the first trimester. SPSS 11.5 (SPSS Inc.) was employed for data analysis.

RESULTS

Women having preconceptional health care utilization were 2.6 times (95%CI: 2.5 to 2.6) more likely to have early initiation of prenatal care compared with women not having preconceptional health care utilization. When stratified by maternal residence, age at delivery, educational attainment, occupation, parity, preconceptional medical disorder, high-risk medical experiences during the first trimester, and preconceptional medical disorders, this association still existed. After controlling for stratification factors mentioned above and the interaction of maternal age, educational attainment, and parity, women having preconceptional health care utilization were 2.7 times (95%CI: 2.6 to 2.8) more likely to have early initiation of prenatal care than were women not having preconceptional health care utilization.

CONCLUSION

Women who had preconceptional health care utilization were more likely to have early prenatal care than were women not having preconceptional health care utilization.

Prevalence and Predictors of Inadequate Prenatal Care: A Comparison of Aboriginal and Non-Aboriginal Women in Manitoba

OBJECTIVE

Despite the importance of prenatal care, there are no national data and limited provincial data on use of prenatal care by women in Canada, nor is there much information on racial/ethnic disparities in access to prenatal care. This study describes and compares the prevalence and predictors of inadequate prenatal care among Aboriginal and non-Aboriginal women giving birth in Manitoba.

METHODS

Data were obtained from interviews with 652 postpartum women who delivered a live singleton infant in 2 tertiary hospitals in Winnipeg, Manitoba. We identified inadequate prenatal care, using the Kessner Adequacy of Prenatal Care Index. We used stratified analysis to describe effect-measure modification for predictors of inadequate prenatal care among the Aboriginal and non-Aboriginal subgroups. We conducted a multivariable logistic regression analysis for the total sample.

RESULTS

A significantly higher proportion of Aboriginal women (15.7%) than non-Aboriginal women (3.6%) received inadequate prenatal care. After controlling for other factors, significant predictors of inadequate prenatal care included low income, low self-esteem, high levels of perceived stress, and Aboriginal background.

CONCLUSION

Women who do not receive adequate prenatal care are more likely to live in poverty, experience highly stressed lives, have low levels of self-esteem, and be Aboriginal. Efforts to improve the provision of prenatal care should be directed toward these women. Racial/ethnic disparities in use of prenatal care need to be addressed.

Prenatal care need and access: a GIS analysis

Many municipalities provide special prenatal care services targeted to low-income women whose access to prenatal care is constrained. For such services to be successful and effective, they must be geographically targeted to the places where low-income, high-need mothers live. This paper presents a GIS analysis of prenatal care need and clinic services for low-income mothers in Brooklyn, NY. We analyze fine-grained geographic variation in need using data on the residential locations of recent mothers who lack health insurance or are covered by Medicaid. Spatial statistical methods are used to create spatially smoothed maps of the density of mothers and corresponding maps of the density of prenatal clinics. For these mothers, clinic density is positively associated with early initiation of prenatal care. Although clinic locations conform relatively well to the residential concentrations of high-need women, we identify several underserved areas with large numbers of needy women and few clinics available.

An issue of culture: the effects of daily activities on prenatal care utilization patterns in rural South Africa

Utilization of healthcare facilities has been extensively analyzed in developed countries by researchers from a wide range of disciplines. However, there is still a need to develop a better understanding of the temporal and spatial factors that affect rural women within developing countries. An important piece of this exploration is addressing time constraints and the cultural context. After time has been spent attending to essential tasks that the entire family is dependent upon, do rural women have "disposable time" left to visit a healthcare facility? The setting for this study is the Ubombo Magisterial District, a northern rural area of KwaZulu Natal, South Africa. Environmental factors and socio-economical factors that motivate or discourage women from utilizing prenatal care are addressed using a multinomial logit model. Many of the factors documented in literature as affecting prenatal care utilization, i.e. age and parity, do not apply in this area. On the other hand, fetching water as a daily activity, which is usually not associated with prenatal care utilization, has a significant effect on utilization.

Men's influences on women's reproductive health: medical anthropological perspectives

Reproductive health has emerged as an organizational framework that incorporates men into maternal and child health (MCH) programs. For several decades, medical anthropologists have conducted reproductive health research that explores male partners' effects on women's health and the health of children. This article summarizes exemplary research in this area, showing how ethnographic studies by medical anthropologists contribute new insights to the growing public health and demographic literature on men and reproductive health. The first half of the article begins by exploring reproductive rights, examining the concept from an anthropological perspective. As part of this discussion, the question of equality versus equity is addressed, introducing anthropological perspectives on ways to incorporate men fairly into reproductive health programs and policies. The second half of the article then turns to a number of salient examples of men's relevance in the areas of contraception, abortion, pregnancy and childbirth, infertility, and fetal harm. Medical anthropological research--as well as prominent gaps in that research--is highlighted. The article concludes with thoughts on future areas of anthropological research that may improve understandings of men's influences on women's reproductive health.

Improving adolescent pregnancy outcomes and maternal health:a case study of comprehensive case managed services

Our findings indicate how health outcomes regarding adolescent pregnancy and maternal and infant health care are intertwined with a case management process that fosters measures that are social in nature-the provision of direct services, as well as the encouragement of informal social supports systems. They also show how case managed services in a small, nongovernmental organization (NGO) with a strong commitment to its clients may provide the spontaneity and caring which results in a "match" between client needs and the delivery of services-and positive outcomes for pregnant women, early maternal health and infant health. The delivery of such case managed services in a manner which is intensive, comprehensive, flexible and integrated contributes significantly to such improved health outcomes.

Barriers to the use of WIC services

OBJECTIVES

To identify barriers that deter parents/caretakers of infants and children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) from taking full advantage of the services provided by the program.

SUBJECTS/SETTING

A total of 3,167 parents/caretakers at 51 New York State WIC local agency sites completed a barriers survey.

DESIGN

Sixty-eight potential barriers to WIC were identified through a literature review, five focus groups with parents/caretakers of WIC participants, and an expert review panel. The barriers survey was administered person-to-person to parents/caretakers of infants and children on WIC. Statistical analysis Classification tree analysis was used to identify characteristics that best predict WIC check usage behavior.

RESULTS

A small set of barriers (n=11) were identified by more than 20% of respondents. Waiting too long was the most frequently cited barrier (48%). Difficulties in bringing the infant/child to recertify and rescheduling appointments were key variables associated with failure to use (ie, pick up or cash) WIC checks. Further analyses indicated that (a) for each additional reported barrier, there was a 2% increase in failure to use WIC checks (P<.0001); (b) waiting for services was related to an increase in the number of people who failed to use checks; and (c) the longer the reported wait, the greater the number of reported barriers (P<.0001).

CONCLUSIONS

Conducting this barriers research enabled the New York State WIC to improve services provided to participants and their families. A decrease in waiting times should generally reduce exposure to noisy, crowded facilities and lead to fewer reports of nothing for kids to do.

Homeless Persons' Decisions to Accept or Reject Public Health Disease-Detection Services

The purpose of this study was to describe the factors that homeless persons report as influencing their decisions to utilize or reject a public health disease-detection program. Although there is copious literature on homelessness, few studies report the real-life perspectives of homeless persons toward health or health promotion. A convenience sample of 55 sheltered and street-dwelling homeless persons, who either resided in or were visiting seven shelters in a large northeastern U.S. city, were interviewed. The interview questions focused on the bases for decisions to accept or reject tuberculosis screening. The in-depth semistructured audio-taped interviews were transcribed, coded, and categorized using Ethnograph software. Interviews were analyzed using the constant comparative content analysis methods. The findings describe homeless persons' reasons for accepting or rejecting a tuberculosis-detection service, the prominent role of shelter personnel in recruitment for health-related interventions, and the confidentiality needs of women with children. This information can assist community health practitioners in designing and advertising health-promotion and disease-detection programming.

Determinants of late prenatal care initiation by African American women in Washington, DC

OBJECTIVES

The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC.

METHODS

DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation.

RESULTS

Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women consideringabortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions.

CONCLUSIONS

The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.