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OCR for page 54
Chapter
Barriers to the Use of
Prenatal care
Interventions to increase the use of prenatal care should be based on a
firm understanding of why some pregnant women do not obtain adequate
prenatal supervision. As a step in that direction, this chapter outlines a
variety of barriers to care that many women face. Four categories of
obstacles are discussed:
1. a set of financial barriers ranging from problems in private insurance
and Medicaid to the complete absence of health insurance;
2. inadequate capacity in the prenatal care system relied on by low-
income women:
3. problems in the organization, practices, and atmosphere of prenatal
services themselves; and
4. cultural and personal factors that can limit use of care.
FINANCIAL BARRJERS
The average bill for having a baby is about $4,300 a figure that
includes hospital and physician charges spanning prenatal care, labor and
delivery services, a postpartum checkup, and hospital services for the
newborn.*) Considering that the typical annual income of a couple in their
*This figure includes both complicated and uncomplicated pregnancies and deliveries as well
as costs associated with health problems in some newborns.
54
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BARRIERS TO THE USE OF PRENATAL CARE
/
55
~ ~ No maternity coverage (15%)
\~
~ //
Medicaid (17%)
CHAMPUS/Other (4%)
Individual private (3%)
Private group (61 %)
FIGURE 2.1 Percentage distribution of all new mothers by insurance coverage at time
of delivery, United States, 1985. SOURCE: Gold RB, Kenney AS and Singh S. Paying for
maternity care in the United States. Fam. Plan. Perspect. 19:19~211, 1987, table 12.
early 20's the prime childbearing years—is about $19,800,2 pregnancy
and childbirth can be a great financial burden. It is therefore not surprising
that financial status, and health insurance coverage in particular, plays a
major role in determining whether or not prenatal care is secured. Despite
the importance of health insurance, an increasing number of Americans
some 37 million at present- are without any. Even those who do have
insurance may have little or no coverage for maternity care.
In this section, three aspects of the insurance problem are discussed: (1)
gaps in private insurance coverage for maternity services; (2) the role of
Medicaid in helping some, but not all, poor women secure prenatal care;
and (3) the problems of women with no health insurance at all. An
excellent analysis of these issues has been published by the Alan Guttma-
cher Institute (AGI).3 The sections that follow draw heavily on that report.
To provide background and context for these sections, Figure 2.1 shows
the type of maternity coverage reported for women who gave birth in 198S.
Although these data reflect payment source at time of delivery and not
payment source for prenatal care exclusively, the two sources generally
correspond quite closely.
Private Insurance
Privately insured women are more likely to obtain adequate prenatal
care than uninsured or Medicaid-enrolled women. The reasons for this
differential include the demographic characteristics of privately insured
OCR for page 56
56
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
income, more education, and so on), the greater
. . . . . .
In
women (higher
availability of providers to women with private insurance twn~cn
turn, is related to more generous reimbursement patterns and other
factors), and the ability of these women to pay in advance for selected
prenatal services.
Some 41 million women (73 percent of women between the ages of 15
and 44) are now covered by private health plans.4 Most private coverage
derives from group insurance, obtained by women on their own or through
their spouse or family as an employment benefit. Since the enactment of
the Pregnancy Discrimination Act in 1978, employers have been required
to offer maternity care benefits in the same manner as other medical
benefits. As a result, many more private plans now include maternity
coverage. In 1977, only 57 percent of employees with new health
insurance policies had maternity care benefits, but by 1982 the number
had increased to 89 percents
Many women do not have access to employer-based group coverage
because they or their spouses are unemployed or work for employers who
do not offer health benefits. Moreover, if the cost to the employee is too
high, the mere availability of an employer-based group insurance plan does
not ensure enrollment. In fact, even enrollment does not guarantee that a
woman will be adequately covered for maternity care or protected from
high cost-sharing burdens. Gaps in coverage, imposition of waiting periods
that may exclucle women already pregnant, recent cutbacks in dependent
coverage under some plans, the growing reluctance of employers to help
finance dependent coverage, shifts and increases in premiums, and
deductible and copayment requirements have all placed new and complex
burdens on women and young families. A few of these problems in private
insurance are discussed in more detail below.
Eligibility for Coverage Although over 80 percent of all privately
insured Americans under age 65 are insured through their employers, over
half of uninsured individuals in 198S were in families where at least one
member had a full-time job.6 Whether employers furnish insurance
depends on their financial status, on how highly they choose to compen-
sate their work force, or both. Small businesses and employers of low-paid
or part-time nonmanufacturing and seasonal workers are less likely to
furnish health insurance or to underwrite the cost of premiums.7 Since
women are disproportionately represented in these categories of workers,
they are less likely to be insured.8 Firms that pay low wages are
substantially less likely to offer subsidized health insurance as part of their
employees benefit packages, even though it is lower paid employees who
are particularly in need of the subsidy.9 Moreover, in recent years
employers who do subsidize employee coverage have begun to reduce or
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BARRIERS TO THE USE OF PRENATAL CARE
in some instances eliminate their contributions.~° Th
57
is trend has particu-
larly serious implications for women employed at minimum wage jobs,
since the minimum wage has remained fixed and unadjusted for inflation
since 1980.
Women who are not in the labor force are almost entirely clependent for
private insurance on their spouses' family coverage through employers'
plans. Thus, women who are not married and are unemployed or
marginally employed are significantly more likely than women who are
married or employed full-time to have no private insurance. Similarly,
nonworking women in poor and near-poor families are particularly
likely to be without private insurance because their spouses, like
low-income workers generally, tend to have no employer-based insur-
ance, to have employer-based insurance covering the working spouse only,
or to have access only to coverage that is too costly to buy. The increase
in single-parent families (whether headed by a divorced or separated
parent or a never-married parent) has also contributed to the growing
number of families without private coverage. Single-parent families are
three to four times more likely to be completely uninsured than two-parent
families. ~ ~
Even women who have coverage may face long waiting periods before
benefits can be obtained. The AGI report notes that:
. . . 58 percent of full-time employees participating in employment related health
insurance programs- including about 20 million women of reproductive age belong
to plans that require a waiting period. . . 18 percent [of such employees] belong to
plans that impose waiting periods of 10 months or more, thus eEectively precluding
any reimbursement for care during pregnancy.
Scope and Depth of Coverage Employees and families with private
insurance are increasingly likely to be covered less comprehensively than
they were in the past. The Pregnancy Discrimination Act of 1978, which
mandates that private insurance plans provide coverage of routine mater-
nity care, does not apply to employers of fewer than IS persons, and not
at} states have enacted remedial legislation of their own to close this gap.
Furthermore, such state laws, where applicable, do not apply to employers
who self-fund their insurance coverage. As a result, some five million
women have insurance plans with virtually no coverage for maternity
care. 13
In addition, insurers have varying policies regarding coverage of labo-
ratory, X-ray, and other supplemental services such as nutritional coun-
seling. Some private insurance plans either fad] to cover benefits that may
be important to pregnancy outcomes or impose limits on coverage
unrelated to medical need. For example, in 198S only US percent of private
plans covered home health care.~4
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58
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
Patient Cost-Sharing Except for prepaid health plans, first-dollar
coverage of prenatal and delivery costs is seldom included in private health
insurance packages. Pregnant women usually pay an initial deductible, and
physicians generally require a relatively large payment in advance for
prenatal care. At the time of delivery, pregnant women may also be asked
to pay a percentage of hospital room charges (typically 20 percent,
sometimes more). Recent employer cost-containment strategies have
included significant increases in deductibles and coinsurance obligations,
which pass the cost directly on to the individual. Although adequate data
on out-of-pocket costs for pregnancy and childbirth among privately
insured women are unavailable, it is apparent that, for some women, the
required cash payments are significant and burdensome.
Medicaid
The Medicaid program is the largest single source of health care
financing for the poor and is generally believed to be primarily responsible
for the increased use of medical services by low-income individuals since
its enactment in 1965. With regard to prenatal care specifically, the
National Center for Health Statistics' (NCHS) nasality data from 1969 (the
first year in which NCHS compiled such data) and 1980 show significant
improvements in the use of prenatal care shortly after Medicaid was
enacted and 11 years later, as evidenced by increases in the proportion of
pregnant women seeking care in the first trimester (Table 1.11~. Since
1980 there has been little improvement, as discussed in Chapter 1. Table
1.11 shows that the greatest increase in use of prenatal care between 1969
and 1980 was among black women. In 1969, 43 percent of black women
and 72 percent of white women initiated prenatal care in the first trimester
of pregnancy. These figures increased to 63 percent for black women and
79 percent for white women in 1980. These differential gains may be due
to the fact that higher proportions of black women were living in poverty
and enrolled in Aid to Families with Dependent Children (AFDC—that is,
welfare) during this period, and AFDC enrollment has traditionally
included eligibility for Medicaid benefits. These findings underscore the
special role of Medicaid in increasing minority access to prenatal care.
Selected state reports confirm the importance of Medicaid in securing
prenatal services. For example, Norris and Williams examined the impact
of Medi-Cal (Califomia's Medicaid program) on perinatal outcomes in
California and found major differentials in prenatal care use among
selected ethnic groups between 1968 and 1978, a period of significant
Medi-Cal expansion. In 1968, Medi-Cal reimbursed costs for 13 percent of
all California births; in 1978, it reimbursed 27 percent. Although the
proportion of women receiving care in the first trimester increased for all
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BARRIERS TO THE USE OF PRENATAL CAM
59
groups in the state during that period (whether enrolled in Medi-Cal or
not), the increase was greatest among enrolled women. For example,
among white (non-Spanish surname) women on Medi-Cal, 46 percent
began prenatal care during the first trimester in 1968; by 1978, that figure
had grown to 65 percent a gain of almost 20 percentage points. Among
white (non-Spanish surname) women not enrolled in Medi-Cal, the
improvement was more modest: 76 percent began care in the first trimester
in 1968 versus 82 percent in 1978.~5
Despite such favorable trends, data also show that women covered by
Medicaid do not obtain prenatal care as early in pregnancy or make as
many visits to providers as women with private insurance. For example,
using data from New York City in 1981, Cooney compared delayed care
among Medicaid recipients with delayed care among women with less than
12 years, education (a proxy measure for low income) who had private
insurance. In 23 out of 30 subgroups defined by race, marital status, and
age, more Medicaid recipients obtained delayed care than women with
third-party insurance. Similarly, a 1986 survey of over 2,000 women in
Texas found that 85 percent of women with private health insurance began
prenatal care in the first trimester versus 40 percent of women enrolled in
Medicaid; about S percent of privately insured women hac} five or fewer
prenatal visits versus 2S percent of women in Medicaid.~7 Data from the
National Survey of Family Growth and several other state surveys confirm
this general picture. i9
It is important to add, however, that few of these studies analyzing use
of prenatal care by insurance coverage control for the changing eligibility
status of women over the course of a pregnancy. In particular, a woman
listed as Medicaicl-enrolled at the time of delivery may not have become
eligible for the program until just before delivery. If, in adclition, she
delayed beginning prenatal care, she will be counted as a Medicaid-
enrollecl woman who began care late, even though her delay in beginning
care and her Medicaid status may or may not have been related.
Despite this methodological problem, at least three factors suggest that
these studies are accurate in their finding that Medicaid is associated with
more limited prenatal care than is private insurance. First, as discussed
later in this chapter, the Medicaid enrollment process is so time-con-
suming that a woman may be well into her pregnancy before her eligibility
is established. Thus, she may have been financially unable to obtain care
earlier. Second, Medicaid-insured women rely more heavily on clinics for
prenatal care than do women with private insurance, and in many
communities these clinics are overburdened and unable to schedule
appointments promptly.20 Also, the number of physicians accepting
Medicaid-enrolled pregnant women has always been limited and in some
areas it is decreasing. (These issues of system capacity are taken up later in
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
TABLE 2.1 Annual Visits to the Doctor and Other Characteristics of
Poor Womena with an Infant Age 3 Months or Younger, National
Health Interview Survey, 1978, 1980, and 1982
Poor Women
Uninsured Medicaid Other Insurance
Characteristic (N= 71) (N= 98) (N= 132)
Annual visits to doctor (no.) 11.0 12.6 13.1
Black (%) 19.7 42.9 18.2
Community type (%)
Central city 28.2 48.0 28.0
Rural 56.3 19.4 40.2
Region (%)
Northeast 9.9 23.5 17.5
South 53.5 24.5 43.9
North central lS.S 31.6 25.0
West 21.1 20.4 13.6
Education (years) 10.9 10.6 11.7
Family income ($ 1982) 1,672 1,438 2,429
Marital status and age (%)
Unmarried, 17-19 9.9 21.4 3.8
Unmarried, 20+ 8.5 45.9 6.1
Married, 17-19 12.7 5.1 12.1
Fair or poor health (%) 14.1 17.3 12.1
NOTE: Insurance status reflects coverage at some time during the interview year. It
was not possible to identify when during the pregnancy coverage of a given type began.
Also, this sample included poor women with an infant age 3 months or younger at the ume
of the interview. Their reported annual visits to a doctor largely reflect prenatal care;
however, a postpartum visit and visits not directly related to the pregnancy were also
included in each woman's total count of visits.
aReal income per family member of less than $3,500 in 1982 dollars.
SOURCE: 1978, 1980, 1982 National Health Interview Surveys; calculations by J.
Hadley for the Once of Technology Assessment, U.S. Congress.
this chapter.) Finally, women on Medicaid are, by definition, at the bottom
rung of the economic ladder and are characterized by numerous other
demographic factors associated with insufficient prenatal care, including
having limited education, being unmarried, under 20, and in fair or poor
health. (See Table 2.1, although note that the table only reports on poor
women; if Medicaid-enrolled women were compared with all women,
evidence of their disadvantage would be more striking.) Given these
attributes of the Medicaid population, health insurance alone is unlikely to
close the gap between their use of health services and that of more affluent
women with private coverage.
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BARRIERS TO THE USE OF PRENATAL CARE
61
It is not as clear how Medicaid-enrolled women compare with uninsured
women in their use of prenatal care. Some studies find that uninsured
women receive quantitatively more adequate care than Medicaid-enrolled
women. For example, a 1986 survey of 517 births in Rhode Island found
that 84 percent of women with private insurance, 70 percent of uninsured
women, and 57 percent of Medicaid-insured women obtained adequate
prenatal care.2i By contrast, a General Accounting Office (GAO) study of
1,157 pregnancies found that both Medicaid-enrolled and privately in-
sured women began care earlier in pregnancy and saw a provider more
frequently than did women with no insurance.22 Hadley examined the use
of prenatal care by pooling data from the 1978, 1980, and 1982 Health
Interview Surveys. He found that when analysis is confined to poor women
only that is, when poverty is held constant- Medicaid-enrolled women
made more visits to a doctor than uninsured women, though less than
privately insured women (Table 2.19.
The picture that emerges from these many data sets is that Medicaid has
improved access to prenatal care for poor women. Enrolled women,
however, still do not obtain as much prenatal care as women with private
insurance, whether measured by trimester in which care was begun or
number of visits. On the other hand, enrolled women probably obtain
more prenatal care than uninsured women (when poverty is held con-
stant), although the data on this relationship are mixed.
Despite the importance of Medicaid in helping many low-income
individuals (including pregnant women) gain access to health care, a
substantial proportion of the poor is not covered by this program. In fact,
in 1988 the average income eligibility ceiling for Medicaid was only 49
percent of the federal poverty level.23 Though designed to meet the
medical needs of the disadvantaged, Medicaid in 1985 "reached less than
half the people under the federal poverty {eve! in 36 states and in 22 of
those states it reached less than a third."24 In addition, the proportion of
the poor covered by Medicaid has decreased: it is estimated that in 1976,
6S percent of the poor were covered by Medicaid; in 1984, the comparable
figure is 38 percent.25
Aware of the inadequate coverage of Medicaid for many pregnant
women and children, Congress has recently expanded eligibility for
Medicaid by means of the Deficit Reduction Act of 1984, the Consolidates!
Ominibus Budget Reconciliation Act of 198S, the Omnibus Budget
Reconciliation Acts of 1986 and 1987, and the Medicare Catastrophic
Coverage Act of 1988. Two of the most important reforms in these laws are
(1) removing the consideration of"household composition" from eligibil-
ity determinations for pregnant women and (2) severing the link between
Medicaid and AFDC. The 1986 law allowed states for the first time to offer
Medicaid to poor children (up to age S) and to pregnant women with
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
incomes up to 100 percent of the federal poverty level, regardless of their
eligibility for welfare or cash assistance under a state's AFDC guidelines.
Two-thirds of the states chose to adopt this expansion, and the 1988 law
requires all states to have such coverage by 1990. The 1987 law permits
states to expand eligibility even further for poor children (up to age 1) and
for pregnant women with incomes up to 185 percent of the federal poverty
level. As of June 1988, six states had done so.26 The importance of separating
Medicaid from welfare merits emphasis. It affords states the opportunity to
increase Medicaid eligibility for particular subgroups, and to receive federal
matching funds, without increasing AFDC program costs.
Also available to states are two other important means of severing health
care financing from welfare in certain ways and for certain groups:
"medically needy" programs and coverage of two-parent families with an
unemployed parent (so-called AFDC-UP or Medicaid-UP programs).
These option and the newer ones noted above are described by the
American Hospital Association in Medicaid Options: State Opportunities and
Strategies for Expanding Eligibility.27
Congress is considering additional reforms to increase Medicaid enroll-
ment among eligible pregnant women and children. For example, a recent
legislative proposal would expand Medicaid to help finance casefinding
and other activities to identify eligible individuals and assist them in
enrolling in the program. The legislation would also require states to
maintain an adequate number of obstetrical providers in the program.
uninsured women
Despite economic recovery and rising employment, lack of health
insurance has become an increasingly important social and economic
problem in the United States in recent years. By the mid-1980s, more than
37 million Americans were completely uninsured.
Women of childbearing age are disproportionately represented among
the uninsured.28 An estimated 26 percent of women of reproductive age
(14.6 million) have no insurance to cover maternity care, and two-thirds
of these (9.5 million) have no insurance at all.
Of poor women, 35 percent are completely uninsured. As one might
anticipate, the women that are most likely to be uninsured are the most
likely to be poor those who are black or Hispanic, poorly educated,
working in low-paying jobs or unemployed, unmarried, or in their early
2o,s.29
Poor women with no insurance face significant obstacles to obtaining
prenatal care. Their options are limited to charity care at the hands of
evicting providers or care in public health clinics and other settings usually
financed by public funds. As the section on system capacity below notes,
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BARRIERS TO THE USE OF PRENATAL CARE
63
in many areas these clinics are so overburdened that prompt entry into
care can be very difficult.
Provision of free care in clinics and other settings can soften the effects
of being uninsured. For example, the GAO study referred to earlier
reported that:
. . . about 86 percent of the interviewees at Cooper Green Hospital in Birmingham,
Alabama, where free prenatal care is available through the public health department,
were uninsured mothers. Yet, none of these women who received insufficient care cited
lack of money as their most important barrier. By contrast, about 27 percent of the
women delivering at Los Angeles County-USC Medical Center who obtained insuffi-
cient care cited lack of money as the most important barrier. About 94 percent of the
births at the hospital were to uninsured mothers. Los Angeles County clinics charge
$20 per visit for the first seven prenatal care v~sits.30
It is not known how extensive the availability of free care is nationally or
what recent trends have been, although a recent survey suggests that state
maternal and child health agencies are able to finance only a small portion
of the prenatal care needed by uninsured women- those most likely to
seek free or reduced cost care.30a
Unfortunately, the proportion of women age 15 to 44 who have no
health insurance is likely to grow. Women increasingly work in industries
least likely to offer health insurance (such as service and retail jobs); they
are also increasingly likely to work part-time, which usually carries no
health insurance benefits.3i Other reasons were noted earlier: growing
gaps in the employer-based insurance system and the decreasing propor-
tion of the poor covered by Medicaid. Although expansions of Medicaid
will help finance care for some portion of uninsured women, the problem of
absent health insurance has outstripped the remedial steps taken thus far.
To sum up, three major themes emerge from the extensive data on the
relationship between use of prenatal care and the availability of private
insurance, Medicaid, or no insurance. First, women with private insurance
are more likely to obtain sufficient prenatal care than those with Meclicaid
coverage or no insurance, although there are troubling gaps in private
insurance coverage. Second, Medicaid has undoubtedly increased access to
prenatal care for low-income individuals, but many poor women are not
covered by the program, particularly in the first months of pregnancy.
Third, a significant number of women have no insurance at all and must
depend on charity care, publicly financed clinics, or other resources to
obtain prenatal services. The size of this last group is likely to expand.
INADEQUATE SYSTEM CAPACITY
Inadequate capacity in the maternity care system often used by low-
income women constitutes a second barrier to use of prenatal care. This
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
section outlines two closely related aspects of the capacity issue: first,
inadequate numbers of, and long waiting times for appointments at,
facilities such as Community Health Centers and health department
clinics- settings that have traditionally provided prenatal care to those
unable or unwilling to use the private care system; and second, problems
concerning the availability of maternity care providers including the
uneven distribution of physicians nationally, the unwillingness of some
physicians to care for Medicaid-enrolled pregnant women, and the mal-
practice problem.
.Servir:es in Organized Settings
Women with limited financial resources, especially women with neither
public nor private health insurance, frequently seek prenatal care in
so-called "organized settings," as distinct from private physicians in
office-based practices. These settings include hospital outpatient depart-
ments, Community Health Centers and Migrant Health Centers, public
health departments, Maternity and Infant Care projects, and school-based
prenatal services.
Several national surveys confirm that these settings are important
sources of care for poor women and for young, unmarried, black, or
Hispanic women the same groups at risk for inadequate use of prenatal
care. For example, the 1982 National Survey of Family Growth (NSFG)
revealed that, although private doctors are the major source of care for
both poor and nonpoor women (S4 and 83 percent, respectively), clinics
are much more important for poor women (that is, women with incomes
of less than 150 percent of the fecleral poverty level). About 39 percent of
poor women used clinics, compared to 12 percent of nonpoor women. The
NSFG also showed that, among pregnant women, about 36 percent of
Hispanic women, 4S percent of black women, 42 percent of women under
age 20, and 47 percent of unmarried women went to a clinic for their first
prenatal visit, as compared with about 10 to IS percent of white, older, and
married women.32 Women enrolled in Medicaid were particularly inclined
to seek prenatal care at clinics: 60 percent of women whose delivery was
paid for at least in part by Medicaid obtained prenatal care at a clinic versus
21 percent of all women.33 The 1980 National Medical Care Utilization
and Expenditures Survey (NMCUES) also shows that poor, minority, and
single pregnant women rely heavily on clinics for prenatal care.34
The special value of these clinics these organized settings—stems from
at least three factors. First, as just noted, they typically provide prenatal
care to uninsured or Medicaid-enrolled women. Second, the poor, the very
young, and persons not part of mainstream culture often need intensive
health education and require assistance in areas beyond medical care, such
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BARRIERS TO THE USE OF PRENATAL CARE
77
her pregnancy and toward prenatal care, her knowledge about such care
and whether she sees it as useful, her cultural values and beliefs, a variety
of other personal characteristics often called life-style, and certain psycho-
logical attributes. This section describes the role of these factors in the use
of prenatal care, but it is important to emphasize at the outset that most
research on personal barriers does not control for the confounding
influence of the prenatal care system itself. That is, little effort has been
macle to assess the nature and extent of personal barriers to care in
different types of prenatal settings.
Attitudes toward pregnancy that may influence efforts to seek prenatal
care include whether the pregnancy is planned or unplanned and whether
the woman views her pregnancy positively or negatively. Many studies
have found that later entry into care and fewer visits are associated with
unplanned pregnancy and, similarly, with negative views of a current
pregnancy.93 These attitudes may influence prenatal care in three ways.
First, women who did not plan their pregnancy may be less aware of the
signs of pregnancy and therefore may recognize their pregnancy later.
Second, women who view their pregnancies negatively may delay prenatal
care while they decide whether to continue the pregnancy. Finally, an
unplanned pregnancy is likely to evoke ambivalent feelings, even in
women who decide to continue the pregnancy. This ambivalence may
result in late entry into or sporadic use of prenatal care. Here it is
important to adct that in the United States, more than half of all
pregnancies are unplanned.93a Given the evidence that unplanned preg-
nancies are associated with late entry into prenatal care, as noted above,
and that the magnitude of unplanned pregnancy in this country is great, it
is reasonable to conclude that more extensive use of family planning
services would result in reduced rates of late entry into prenatal care.
Attitudes toward prenatal care itself are also influential. Not all women
believe that prenatal care is important and worth the effort to seek it out.94
Some believe that pregnancy is a normal event not needing medical
supervision, or that care is needed only if a pregnant woman feels ill; a few
women may actually be unaware of what prenatal care is. Previous,
unsatisfying experiences with prenatal services may also act as a deterrent.
The provider practices and clinic policies outlined above no doubt leave
some women with a negative view of prenatal care, reluctant to seek it out
in subsequent pregnancies. Studies that have assessed the relationship
between attitudes about prenatal care and onset of care show that women
who believe the service is important and should be initiated early are more
likely to begin care in the first trimester than those attaching less
importance to early care.9596 The predictive value of positive attitudes
toward prenatal care should not be overestimated, however. Oxford et al.
noted that, among a sample of women who began care in the third
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
trimester, i2 percent reported that they thought prenatal care should begin
during the first few weeks of pregnancy.97
Not knowing the signs of pregnancy is also related to use of prenatal
services. Studies report that between 16 and 33 percent of women who
received insufficient care did not know the signs of pregnancy.9~0i
Cultural values may affect efforts to seek out prenatal care. Among some
cultures, pregnancy is regarded as a healthy condition not requiring
medical treatment or a physician's advice.~02 Furthermore, the perception
of what constitutes a health problem may vary between patient and
provider. In one study, for example, low-income, primarily black women
characterized high-risk behavior as not taking prenatal vitamins and
catching the flu, but having more than five children or a previous low
birthweight infant were not viewed as conditions constituting risk.~03
Fear as a barrier deserves special comment. There may be at least four
types of fear: fear of providers or medical procedures, fear of others'
reactions to the pregnancy, fear that one's illegal status in the country will
be discovered, and fear that such health-compromising habits as substance
abuse or smoking will be uncovered and pressures to change brought to
bear. With regard to the first fear, a survey of women who had received no
prenatal care found that S2.4 percent indicated fear of hospitals, doctors,
or procedures as a primary reason for not seeking care.~°4 In her in-depth
interviews with disadvantaged women who had suffered an infant death,
Boone found that "fear of doctors and nurses represented the single most
important factor in their perception of health care providers as inac-
cessible."~05
Adolescents are particularly likely to cite fear as a reason for not seeking
early care. While some pregnant adolescents fear medical procedures,
many also fear the pregnancy itself and parental response. A postpartum
teenager who delayed care explained, "When I went to the doctor I was
6i months I found out when I was 8 weeks. I didn't go right away because
it took me that long to tell my mom."~06 For teenagers who may be eligible
for Medicaid during a pregnancy, concerns about confidentiality may be
significant. Although procedures vary widely, most states do not have
Medicaid policies and practices that protect teenagers' confidentiality.
States generally provide a family with only one Medicaid card, which
forces teenagers to ask their parents for use of the card before seeking
services. i07 Unless they are assured confidentiality, adolescents may
choose to protect their secret rather than seek prenatal care.
Another group for whom fear can be a major barrier to prenatal care is
illegal immigrants, who may not seek care because they are afraid that they
will be reported to the Immigration and Naturalization Service (INS) and
eventually deported.~08 i09 While reporting is not routine in a clinic, the
mere possibility can be a sufficient deterrent. In Los Angeles County, for
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BARRIERS TO THE USE OF PRENATAL CARE
79
example, the board of supervisors recently voted to require all persons
requesting free or reduced-cost health services to apply first for Medi-Cal,
which, in turn, requires completing a form that is sent to the INS. While
the policy never went into effect because of a court injunction, it created
substantial anxiety among undocumented families. A CHC pediatrician in
Los Angeles County reported that the fear generated by the proposal led to
an immediate decrease of SO percent in the number of children attending
his clinic.~°
Pregnant women who are aware that their life-styles place their health
and that of their babies at risk may also fear seeking care because they
anticipate sanction or pressure to change such habits as drug and alcohol
abuse, heavy smoking, and eating disorders. Substance abusers in partic-
ular may delay care because of the stress and disorganization that often
surround their lives, and because they fear that if their use of drugs is
uncovered, they will be arrested and their other children taken into
custody.
The issue of drug abuse during pregnancy deserves additional comment.
The Chao et al. study in Harlem found that women with insufficient
prenatal care were far more likely to report use of heroin, cocaine, or both
than women who obtained care early in pregnancy. Poland et al. found
that 31 percent of a group of women with inadequate prenatal care abused
drugs, mainly heroin, compared with 7 percent of women with more
adequate care. Numerous reports detail alarming increases in the
proportion of women, including pregnant women, who abuse heroin and
cocaine and the resulting rise in the number of babies born with varying
degrees of addiction. For example, from January through November 1987,
142 drug-addicted babies were born at a hospital located in a low-income
area of Washington, D.C. In 1986, by contrast, there had been S5 such
births, and in 1985, 19.~3 Drug abuse among pregnant women has
become especially alarming recently because of the Lightened risk that
these women carry the human immunodeficiency virus (HIV, cause of
AIDS), which can be passed on to the developing baby. In some areas of
New York City, for example, between 4 and S percent of pregnant women
are estimated to be infected with the virus.~4
Homelessness is also associated with poor use of prenatal care. Chavkin
et al. compared the use of prenatal services among women living in New
York City hotels for the homeless, women living in the city's low-income
housing projects, and all other city residents. Forty percent of the hotel
residents studied who had given birth between 1982 and 1984 had
received no care at all, versus IS percent of the housing project group and
9 percent of the citywide group. Only 30 percent of the hotel residents had
made seven or more visits, versus S8 percent of the housing project group
and 68 percent of the citywide group. Unfortunately, homelessness has
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80
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
increased in recent years, and the majority of homeless families are
single-parent households headed by women.~5
Having friends and family to offer emotional support and tangible
assistance and having well-developed skills in overcoming isolation, may
minimize or eliminate barriers to prenatal care; lack of these assets may
constitute an impediment to attaining services. Women vary in the amount
of these resources and in their ability to adapt in a stable and organized
manner to such major changes in life as pregnancy. Several studies suggest
that when emotional support is present—positive interest in the pregnancy
by the father, for example, or the presence of someone with whom to share
the knowledge of pregnancy the probability of using prenatal care
increases. In the absence of such support, particularly in combination with
general social isolation, the likelihood of using prenatal care de-
creases.~8 Similarly, lack of close ties to family and friends may limit
use of prenatal care. The importance of these individuals as sources of
information about specific clinics or services is well known; if such
networks are in disrepair, it will be harder for a woman to connect with
needecl care.
Stress may decrease a woman's ability to seek prenatal care. For some
women, the pressures of daily life are such that prenatal services are of low
priority. A study of more than 2,000 women in Massachusetts found that
women with inadequate care were significantly more likely than women
with adequate care to report being very worried or upset during the
pregnancy due to lack of money, problems with the baby's father, housing
difficulties, lack of emotional support, and related burdens.~9
Such factors as depression and, in particular, denial have also been
associated with poor use of prenatal care. Although denial that one is
pregnant can occur in women of any age, it is often reported in studies of
pregnant adolescents. Denial in adolescence often begins as the belief that
one is not likely to get pregnant ("It won't happen to me") and continues
into pregnancy ("I did not want to accept the fact that I was preg-
pant". i2i Denial is withholding information from oneself; conceal-
ment, a related behavior, is the withholding of information from others.
Furstenberg reports that one-half of 404 adolescents studied clid not tell
their parents that they were pregnant for several months. In most cases, the
adolescents' mothers either learned of the pregnancy from others or
detected it themselves. The prevalence of denial and concealment in
adolescents is related to embarrassment about their changing bodies,
reluctance to share personal information about their sexuality, lack of
knowledge about where to obtain birth control, confusion about the safety
and proper practice of contraception, fear of parental disapproval and
punishment, and, as noted earlier, fear of pelvic examinations and other
medical procedures.~23
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BARRIERS TO THE USE OF PRENATAL CARE
TABLE 2.2 Barriers to the Use of Prenatal Care
81
I. Sociodemographic correlates
Poverty
Inner-city or rural resident
Minority
Under 18 or over 39
Higher parity
Non-English speaking
Unmarried
Less than high school education
II. System barriers
. . . .
Inac equates In private Insurance
policies (waiting periods,
coverage limitations, coinsurance
and deductibles, requirements for
up-front payments)
Absence of either Medicaid or
private insurance coverage of
maternity services
Inadequate or no maternity care
providers for Medicaid-enrolled,
uninsured, and other
low-income women (long wait
to get appointment)
Inadequate transportation services,
long travel time to service sites,
or both
Difficulty obtaining child care
Poor coordination between
pregnancy testing and prenatal
services
Inadequate coordination among
such services as WIC and
prenatal care
Complicated, time-consuming
process to enroll in Medicaid
Availability of Medicaid poorly
advertised
Inconvenient clinic hours,
especially for working women
Long waits to see physician
II. System barriers (Continued)
Language and cultural
incompatibility between providers
and clients
Poor communication between clients
and providers, exacerbated by short
interactions with providers
Negative attributes of clinics,
including rude personnel,
uncomfortable surroundings, and
complicated registration procedures
Limited information on exactly
where to get care—phone
numbers and addresses
III. Barriers based on beliefs, knowledge,
attitudes, and life-styles
Pregnancy unplanned or viewed
negatively, or both
Ambivalence
Signs of pregnancy not known or
recognized
Prenatal care not valued or
understood
Fear of doctors, hospitals,
procedures
Fear of parental discovery
Fear of deportation or problems
with the Immigration and
Naturalization Service
Fear that certain health habits will
be discovered and criticized
(smoking, eating disorders, drug
or alcohol abuse)
Selected life-styles (drug abuse,
homelessness)
Inadequate social supports and
personal resources
Excessive stress
Denial or apathy
Concealment
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82
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
SUMMARY
Table 2.2 summarizes the many barriers to use of prenatal care discussed
in this chapter, as well as the sociodemographic correlates of prenatal care
use defined in Chapter 1. As this daunting list makes clear, many factors
that impede use of prenatal care are external to women themselves; they
are centered primarily in the financial underpinning of the prenatal care
system and in the capacity and practices of various service networks. The
pervasive influence of poverty is noteworthy- many of the barriers are
strongly associated with low income. The list also helps to show that
women's beliefs, knowledge, attitudes, and feelings influence their use of
prenatal services, as do such behaviours and conditions as substance abuse
and homelessness.
REFERENCES AND NOTES
Alan Guttmacher Institute. Blessed Events and the Bottom Line: The Financing of
Maternity Care in the United States. New York, 1987, p. 18.
2. U.S. Bureau of the Census. Money income of households, families and persons in
the United States: 1984. Current Population Reports. Series P-60, No. 151, 1986,
table 31.
3. Alan Guttmacher Institute. Op. cit. Also published by the Alan Guttmacher
Institute as a companion volume is The Financing of Maternity Care in the United
States. New York, 1987.
4. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 20.
5. Gold RB and Kenney AM. Paying for maternity care. Fam. Plan. Perspect.
17:103-111, 1985.
6. Chollet D. A Profile of the Non-Elderly Population Without Health Insurance.
Washington, D.C.: Employee Benefit Research Institute, 1987.
7. Ibid.
8. Gold RB and Kenney AM. Op. cit.
9. AS Hansen, Inc. Health Care Survey, January 20, 1986. In Medical Benefits.
Charlottesville, Va.: Kelley Communications, 1986, pp. 1-2.
10. Wilensky G. Parley P. and Taylor A. Variations in health insurance coverage:
Benefits vs. premiums. Milbank Mem. Fund Q. 62: 134-155, 1984.
11. Sulvetta M and Schwartz C. The Uninsured and Uncompensated Care. Washing-
ton, D.C.: National Health Policy Forum, 1986.
12. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 22.
13. Ibid., p. 21.
14. U.S. General Accounting Office. Health Insurance: Comparison of Coverage for
Federal and Private Sector Employees. Pub. No. GAO/HRD-87-32BR. Washing-
ton, D.C.: Government Printing Office, 1986.
15. Norris ED and Williams RL. Perinatal outcomes among Medicaid recipients in
California. Am. J. Public Health 74:1112-1117, 1984.
16. Cooney JP. What determines the start of prenatal care? Medical Care 23:986-997
1985.
17. Johnson CD and Mayer JP. Texas OB Survey: Determining the Need for Maternity
Services in Texas. College Station, Tex.: Public Policy Resources Laboratory, 1987.
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BARRJERS TO THE USE OF PRENATAL CARE
83
18. Pamuk ER, Horn MC, and Pratt WE. Determinants of prenatal care utilization:
Data from the 1982 National Survey of Family Growth. Paper presented at the
American Public Health Association annual meeting, New Orleans, 1987.
19. See, for example, McDonald TP and Cobrun AF. The Impact of Variations in
AFDC and Medicaid Eligibility on Prenatal Care Utilization. Portland: Health
Policy Unit, Human Services Development Institute, University of Southern
Maine, 1986.
20. Fingerhut LA, Makuc D, and Kleinman JC. Delayed prenatal care and place of first
visit: Differences by health insurance and education. Fam. Plan. Perspect.
19:212-214, 1987.
21. O'Connell J. The Association Between Lack of Transportation and Lack of Child
Care and the Adequacy of Prenatal Care. Providence: Rhode Island Department of
Health, 1987.
22. U.S. General Accounting Office. Prenatal Care: Medicaid Recipients and Unin-
sured Women Obtain Insufficient Care. Pub. No. GAO/HRD-87-137. Washing-
ton, D.C.: Government Printing Office, 1987.
23. Hill I. Reaching Women Who Need Prenatal Care: Strategies for Improving State
Perinatal Programs. Washington, D.C.: National Governors' Association, Center
for Policy Research, 1988, p. 8.
24. Freedman SA, Klepper BR, Duncan RP, and Bell SP. Coverage of the uninsured
and underinsured: A proposal for school enrollment-based family health insur-
ance. N. Engl. I. Med. 18:843-847, 1988, p. 844.
25. Rosenbaum S. Hughes DC, end Johnson D. Maternal and child health services for
medically indigent children and pregnant women. Med. Care 26:315-332, 1988,
p. 315.
26. Ian Hill, National Governors' Association. Personal communication, 1988.
27. American Hospital Association. Medicaid Options: State Opportunities and
Strategies for Expanding Eligibility. Chicago, 1987.
28. National Center for Health Statistics. Health care coverage by sociodemographic
and health characteristics, United States. Prepared by Ries P. Vital and Health
Statistics, Series 10, No. 162. DHHS Pub. No. (PHS)87-1590. Washington, D.C.:
U.S. Public Health Service, 1987.
29. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 43.
30. U.S. General Accounting Office. Op. cit., p. 38.
30a.Rosenbaum S. Hughes DC, and Johnson D. Op. cit.
31. U.S. Bureau of the Census. Statistical Abstract of the United States, 1987.
Washington, D.C.: Government Printing Office, 1986, pp. 371~12; and Chollet
D.Op.cit.,p.18.
32. Alan Guttmacher Institute. The Financing of Maternity Care. Op. cit., tables 17
and 20.
33. ibid.
34. Kovar MG and Klerman LV. Who pays for prenatal care? Data from the National
Medical Care Expenditure Survey, 1980. Paper delivered at the American Public
Health Association annual meeting, Anaheim, California, 1984.
35. Sokol RI, Woolf RB, Rosen MG, and Weingarden K. Risk, antepartum care and
outcome: Impact of a Matemity and Infant Care project. Obstet. Gynecol.
56:15~156, 1980.
36. Public Health Foundation. Unpublished data, 1987.
37. Bureau of Health Care Delivery and Assistance, U.S. Department of Health and
Human Services. Unpublished data, 1988.
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84
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
38. Brooks EF and Miller CA. Recent changes in selected local health departments:
Implications for their capacity to guarantee basic medical services. Am. J. Prevent.
Med. 3:134-141, 1987.
39. Rogers T. Rhodes K, and Silberman I. Report by the Prenatal Appointment
Backlog Task Force. Los Angeles: Programs Division, Department of Health
Services, City of Los Angeles Health Department, 1987.
40. Demand for prenatal care bogs down public clinics. Los Angeles Times. Novem-
ber 8, 1987.
41. U.S. General Accounting Office. Op. cit., p. 41.
42. Southern California Child Health Network and the Children's Research Institute
of California. Back to Basics: Improving the Health of California's Next Genera-
tion. Santa Monica, 1987, pp. 79-80.
43. Kalmuss D, Darabi KF, Lopez I, Caro FG, Marshall E, and Carter A. Barriers to
Prenatal Care: An Examination of Use of Prenatal Care Among Low-Income
Women in New York City. New York: Community Service Society, 1987.
44. Johnson C. Current Perspectives on Prenatal Care. Lansing, Mich.: University
Associates, 1984.
45. President's Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research. Securing Access to Health Care, Vol. 1.
Washington, D.C.: Government Printing Office, 1981, p. 81.
46. Southern California Child Health Network and the Children's Research Institute
of California. Op. cit., p. 88.
17. American College of Obstetricians and Gynecologists. Unpublished data, 1987.
48. Dorn S and Dallek G. Medi-Cal Maternity Care and A.B. 3021: Crisis and
Opportunity. Los Angeles: National Health Law Program, 1986.
49. Mitchell IB and Schurmann R. Access to private obstetrics/gynecology services
under Medicaid. Med. Care 22:1026-1037, 1984.
50. Orr MT and Forrest]D. The availability of reproductive health services from U.S.
private physicians. Fam. Plan. Perspect. 17:63-69, 1985.
51. Lewis-Idema D. Provider participation in public programs for pregnant women
and children. Washington, D.C.: National Governor's Association, 1988, p. 3.
52. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 34.
53. Committee to Study the Prevention of Low Birthweight. Preventing Low Birth-
weight. Washington, D.C.: National Academy Press, 1985, pp. 160-161.
54. American College of Obstetricians and Gynecologists. Professional Liability
Insurance and Its Effects: Report of a Survey of ACOG's Membership. Washing-
ton, D.C., 1983.
SS. American College of Obstetricians and Gynecologists. Survey of Professional
Liability and Its Effects: Report of a 1987 Survey of ACOG's Membership.
Washington, D.C., 1988.
56. American Academy of Family Physicians. Professional Liability Study. Kansas City,
Mo., 1986.
57. Lewis-Idema. Op. cit., pp. 21-25.
58. Oregon Medical Association. The Impact of Malpractice Issues on Patient
Care: Declining Availability of Obstetrical Services in Oregon. Portland, 1987,
p. 1.
59. Ibid., p. 3.
60. See the commissioned paper by Rosenbaum and Hughes at the end of this report.
61. National Association of Community Health Centers. Medical malpractice: Here
we go again. Washington, D.C.: NACH newsletter. Winter 1986.
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BARRIERS TO THE USE OF PRENATAL CARE
85
62. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia.
Personal communication, 1987.
63. Lewis-Idema. Op. cit., p. 25.
64. Southern Regional Task Force on Infant Mortality, Southern Governors' Associ-
ation. Unpublished data, 1985.
O , -I
65. Professional Management Associates, Inc. Improving MCH/WIC Coordination
Final Report and Guide to Good Practices. Report submitted to the Office of the
Assistant Secretary of Planning and Evaluation, Department of Health and Human
Services. Contract No. HHS-100-84-0069. Washington, D.C., 1986.
66. Christison-Lagay J and Crabtree BE. Barriers Affecting Entry into Prenatal Care:
A Study of Adolescents Under 18 in Hartford, Connecticut. Hartford: City of
Hartford Health Department, 1984.
67. Toomey BG. Factors Related to Early Entry into Prenatal Care: A Replication.
Columbus: Bureau of Maternal and Child Health, Ohio Department of Health,
1985.
68. See, for example, Learner M, Stephens T. Sears AH, and Efirt C. Prenatal Care in
South Carolina: Results from the Prenatal Care Survey. Columbia: Department of
Health and Environmental Control, 1987. With regard to usual source of care and
pediatrics, see Kasper ID. The importance of type of usual source of care for
children's physician access and expenditures. Med. Care 25:38~398, 1987.
69. National Govemor's Association. Selected State Medicaid Survey. Washington,
D.C., 1986.
70. Alan Guttmacher Institute. Blessed Events. Op. cit., p. 32.
71. Alan Guttmacher Institute. The Financing of Maternity Care. Op. cit., pp. 169-170.
72. Ian Hill, National Governors' Association. Personal communication, 1988.
73. Ibid.
74. U.S. General Accounting Office. Op. cit. See also American College of Obstetri-
cians and Gynecologists. Health Care for Mothers and Infants in Rural and
Isolated Areas. Washington, D.C., 1978. See also O'Connell J. Op. cit.
75. U.S. General Accounting Office. Op. cit., p. 40.
76. American Nurses' Association. Access to Prenatal Care: Key to Preventing Low
Birthweight. Kansas City, Mo., 1987, pp. 27-28.
77. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia.
Personal communication, 1987.
78. Dana Hughes, Children's Defense Fund. Personal communication, 1988.
79. Select Panel for the Promotion of Child Health. Better Health for Our Children:
A National Strategy, Vol. 1. DHHS Pub. No. (PHS)79-55071. Washington, D.C.:
Government Printing Office, 1981.
80. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia.
Personal communication, 1987.
81. Peterson P. A Time Flow Study: Hutzel Prenatal Clinic. Detroit: Wayne State
University, 1987.
82. Research and Special Projects Unit. Pregnant Women and Newborn Infants in
California: A Deepening Crisis in Health Care. Summary of Hearings held
March-April, 1981. Sacramento: California State Department of Consumer
Affairs, 1982.
83. Kalmuss D et al. Op. cit., p. 47.
84. Ross CE and Duff RS. Returning to the doctor: The effect of client characteristics,
type of practice, and experience with care. J. Health Soc. Behav. 23:119-131,
1982.
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86
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
85. Poland M, Ager IW, and Olson IM. Correlates of prenatal care. Paper presented
at the American Public Health Associates annual meeting, Las Vegas, 1986, p. 9.
86. See, for example, Juarez Associates. How to Reach Black and Mexican-American
Women. Report submitted to the Public Health Service, Department of Health
and Human Services. Contract No. 282-81-0082. Washington, D.C., 1982. See
also Wan TH. The differential use of health services: A minority perspective.
Urban Health 2:47-49, 1977.
87. Kalmuss D et al. Op. cit., p. 48.
88. Failer H. Perinatal needs among immigrant women. Pub. Health Rep.
100(May-June):340-343, 1985.
89. Kalmuss D et al. Op. cit., p. 47.
90. Chavez LR, Cornelius WA, and Jones OW. Utilization of health services by
Mexican immigrant women in San Diego. Women's Health 11:~20, 1986.
91. Johnson CD and Mayer JP. Op. cit.
92. Klein L. Nonregistered obstetric patients: A report of 978 patients. Am. I. Obstet.
Gynecol. 110:795-802, 1971.
93. See, for example, Brown MA. Social support during pregnancy: A unidimensional
or multidimensional construct? Nurs. Res. 35:4-9, 1986. See also Kleinman IC,
Machlin SR, Cooke MA, and Kessel SS. The relationship between delay in seeking
prenatal care and the wontedness of the child. Paper presented at the American
Public Association annual meeting, Anaheim, California, 1984. Chapter 3
contains additional discussion of this topic.
93a.Jones EF, Forrest ID, Henshaw SK, Silverman I, and Torres A. Unintended
pregnancy, contraceptive practice and family planning services in developed
countries. Fam. Plan. Perspect. 20:5~67, 1988, p. 55.
94. Poland ML and Giblin PT. Personal barriers to the utilization of prenatal care.
Paper prepared for the Committee to Study Outreach for Prenatal Care. Institute
of Medicine, Washington, D.C., 1987.
95. Toomey BG. Op. cit.
96. Bowling IM and Riley P. Access to Prenatal Care in North Carolina. Raleigh:
North Carolina State Center for Health Statistics, 1987.
97. Oxford L, Schinfeld SG, Elkins TE, and Ryan GM. Deterrents to early prenatal
care. J. Tenn. Med. Assoc. November:691~95, 1985.
98. Cumbey DA. Improved Child Health Project. Columbia, S.C.: Bureau of Maternal
and Child Heald~, Department of Health and Environmental Control, 1979.
99. Johnson CD and Mayer JP. Op. cit.
100. Warrick L. A model for examining barriers to prenatal care and implications for
outreach strategies. Paper presented at the American Public Health Association
annual meeting, New Orleans, 1987.
101. Poland ML, Ager JW, and Olson IM. Barriers to receiving adequate prenatal care.
Am. J. Obstet. Gynecol. 157:297-303, 1987.
102. Warrick L. Op. cit.
103. Poland ML. Ethical issues in the delivery of quality care to pregnant women. In
New Approaches to Human Reproduction, Social and Ethical Dimensions,
Whiteford L and Poland ML, eds. Boulder, Colo.: Westview Press, in press.
104. Chao S. Imaizumi S. Gorman S. and Lowenstein R. Reasons for absence of
prenatal care and its consequences. New York: Department of Obstetrics and
Gynecology, Harlem Hospital Center, 1984.
105. Boone M. Social and cultural factors in the etiology of low birthweight among
disadvantaged blacks. Soc. Sci. Med. 20:1001-1011, 1985, p. 1008.
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BARRIERS TO THE USE OF PRENATAL CARE
87
106. Knoll K. Barriers and motivators for prenatal care in Minneapolis. Minneapolis:
Minnesota Department of Health, 1986, p. IS.
107. Children's Defense Fund. Unpublished data, 1985.
108. American Medical Association. Medical care for indigent and culturally displaced
obstetrical patients and their newborns. I. Am. Med. Assoc. 245:1159-1160, 1981.
109. Scrimshaw SCM, Engle PM, and Horsley K. Use of prenatal services by women of
Mexican origin and descent in Los Angeles. Los Angeles: University of California
at Los Angeles, 1985.
110. Research and Special Projects Unit. Op. cit., p. S1.
111. Chao S et al. Op. cit.
112. Poland ML et al. Op. cit.
113. Drugs get choke hold in early stages of life. Washington Post, January 17, 1988.
114. Margaret Haegarty, Harlem Hospital Center. Personal communication, 1988.
115. Chavkin W. Kristal A, Seabron C, and Guigli P. The reproductive experience of
women living in hotels for the homeless in New York City. N.Y. State ]. Med.
January:1~13, 1987.
116. Boone M. Op. cit.
117. Poland ML et al. Op. cit.
118. Giblin PT, Poland M, and Sachs B. Pregnant adolescents' health information
needs: Implications for health education and health seeking. I. Adol. Health Care
7:168-172, 1986.
119. Johnson S. Gibbs E, Kogan M, Knapp C, and Hansen.JH. Massachusetts Prenatal
Care Survey: Factors Related to Prenatal Care Utilization. Boston: SPRANS
Prenatal Care Project, Massachusetts Department of Public Health, 1988.
120. Cumbey DA. Op. cit.
121. Cogswell BE and Fellow C. Adolescents' perspectives on the health care system:
A determinant of fertility. Report submitted to the National Institute of Child
Health and Human Development. Contract No. 1-HDE28737. Bethesda, Md.,
1982.
122. Furstenberg, Jr. FF. The social consequences of teenage parenthood. Fam. Plan.
Perspect. 8:148-164, 1976.
123. Cogswell BE and Fellow C. Op. cit.
Representative terms from entire chapter:
pregnant women
