Prenatal care among low-income women

ADEQUATE PRENATAL CARE has the potential to improve family well-being and reduce societal costs through healthier birth outcomes (Hughes, Johnson, Rosenbaum, Simons, & Butler, 1988). Women with late or no prenatal care are more likely to have low-birth-weight infants, which in turn create more problems for women, families, health-care providers, and society (Institute of Medicine, 1985). Numerous studies have identified financial, system, and demographic factors that contribute to women's late use of prenatal care. The majority of research has focused on barriers to prenatal care. Little information has been available on family members' influence on women's care use or women'S perception of rewards for obtaining prenatal care. The purpose of the study described in this article was to identify personal, family, and provider rewards and costs that affect prenatal care use among low-income women.

Review of the literature indicates that researchers have identified numerous factors that contribute to women'S late or inadequate use of prenatal care. A major contributing factor has been lack of financial resources or insurance coverage (Government Accounting Office, 1987; Cooney, 1985; Oberg, Lia-Hoagberg, Hodkinson, Skovholt, & Vanman, 1990). Approximately one-fourth of American women of reproductive age have no insurance to cover maternity care (Gold, Kenney, & Singh, 1987), and enrollment in a Medicaid program does not ensure that women will obtain care (McDonald & Coburn, 1988).

Other studies identified structural factors, such as lack of child care and transportation, that prevent women from obtaining care (Government Accounting Office, 1987). Health-care-system factors such as inconvenient schedeules, long waits for appointments, inaccessible clinic locations, lack of continuity with a provider, and poor communication with providers were also associated with reduced prenatal care (Oberg, Lia-Hoagberg, Skovholt, Hodkinson, & Vanman, 1991).

Some studies have suggested that psychosocial factors affect women's decisions to delay prenatal care. These factors include nonacceptance of or ambivalence about the pregnancy (Lia-Hoagberg et al., 1990; Young, McMahon, Bowman, & Thompson, 1990); fear of a negative response or lack of interest from family, boyfriend, or others (Poland, Ager, & Olson, 1987); and feeling depressed or not being well enough to attend an appointment (Kalmuss & Fennelly, 1990).

Demographic factors associated with less adequate prenatal care use include young maternal age, less than a high school education, unmarried status, a greater number of children, unemployed, and low family income (Government Accounting Office, 1987; St. Clair, Smeriglio, Alexander, Connell, & Niebyl, 1990; Leatherman, Blackburn, Davidhizar, 1990).

EXCHANGE THEORY

Exchange theory (Nye, 1979) provides a relevant theoretical framework for examining women'S decisions regarding obtaining prenatal care. The theory suggests that humans avoid relationships, interactions, and feeling states that are dissatisfying or costly and seek out situations and experiences that are gratifying, pleasurable, or rewarding. Pregnant women make decisions about obtaining prenatal care on the basis of their perceptions of rewards and costs for themselves and their families. Rewarding relationships and interactions with family members and providers are more likely to increase the pregnant woman's perceptions of gain from prenatal care. Although numerous studies have examined the barriers to or costs of obtaining prenatal care, little research has focused on the rewards for women. Such research is important because knowledge of these factors could be used by families, providers, and communities to increase the rewards or incentives for care and decrease the number of women who do not obtain sufficient care.

Method

The study sample consisted of 40 low-income women who received prenatal care during late 1990 and early 1991 in two publicly funded clinics administered by a midwestern city health department. Subjects had had at least two prenatal visits and agreed to participate in the study. The women were informed about the research procedures, asked to sign a consent form prior to the interview, and were interviewed in the clinics while waiting for their appointments. The interviews lasted 10 to 15 minutes and were conducted by a single interviewer in a semiprivate area of the clinic.

A structured interview format and a card-sort procedure were used to obtain information on demographic and prenatal-care variables, the rewards and costs experienced in obtaining prenatal care, and family influence. The women were asked the following questions to explore how prenatal care could become more rewarding for them: (1) Why did you decide to seek prenatal care? (2) What do you want from your prenatal care? (3) How do family members and your partner influence whether you come for prenatal care? (4) How does prenatal care help you and your family? (5) What should your prenatal care providers do for you that they are not doing now, and what do they do that isn't necessary? (6) What interferes with or gets in the way of your obtaining prenatal care? Responses to these questions were recorded in the subjects' words.

A card-sort procedure was developed on the basis of research studies and other literature concerning barriers to and motivators in obtaining prenatal care. Evaluations of the research findings yielded a list of 19 reward and 22 cost items. Tables 1 and 2 identify the reward and cost items and their reference sources. (Tables 1 and 2 omitted) Some of the reward and cost items were found in more than one source. Following a pilot study of the card-sort procedure, items were changed to enhance clarity and understanding. Rewards (categorized as help) and costs (categorized as problems) were presented in random order to the subjects. The women were asked to sort the cards into two piles based on a "true" or "not true" response, then asked to choose the five most important help items. Because only a few problems were chosen by the women, they were not asked to select the five most important problems. Subjects were asked to explain how each of the five chosen help items was important and to elaborate on the chosen problems.

Data analysis included a content analysis of the women'S responses to questions about prenatal care. Responses generally were not lengthy and were easily recorded in written form by the interviewer; none of the women refused to answer questions. The women's responses to each of the six structured interview questions were organized according to the primary content theme. Some subjects' responses to a single question addressed more than one theme. The numbers of subjects responding with particular content themes were then tabulated for each question. Some overlap in responses to questions 1, 2, and 4 occurred, indicating important themes about factors affecting the women's use of prenatal care.

Women's comments were organized under the label of the specific reward or cost. Specific comments made by the women were then selected to illustrate their viewpoints in the descriptions of personal, family, and provider rewards and costs affecting prenatal-care use. Frequencies and percentages were determined for demographic and prenatal-care data, reward and cost items selected by subjects, and structured interview questions that had separate categorical responses. Percentages for the five most important rewards were also determined. Appropriate chi square and correlational analyses were calculated.

FINDINGS

Sample Demographics

Ages of the women ranged from 15 to 40 years, with a mean age of 22.7 years. Approximately half of the women were white 47.5%) and half were nonwhite (52.5%); the majority of nonwhite women were African American (Table 3) (Table 3 omitted). Differences among demographic or prenatal-care variables between the white and nonwhite subjects were not significant. The majority (87.5%) of the women were unmarried. Seventy percent perceived themselves as having a partner, but only 45% said they lived with a husband or boyfriend. More than half were high school graduates; non-high school graduates were often in school or were completing high school equivalency requirements. One-third of the sample had experienced a complication in a previous pregnancy, and slightly more than one-third had living children. The majority of the women (87.5%) started their prenatal care within the first three months of pregnancy. Most of the women (92.5%) were enrolled in Medicaid or were in the process of applying for this benefit.

Slight differences were noted when comparing characteristics of the sample with the general clinic population of 282 pregnant women admitted for prenatal care in the health department clinics during 1991. The study sample included more women who were younger, nonwhite, single, and had a higher level of education and had started prenatal care earlier.

Rewards and Costs of Prenatal Care

Women chose more rewards than costs in the card-sort procedure (Tables 1 and 2). Total rewards chosen ranged from 9 to 19 per subject, with a mean of 14 rewards, whereas total costs ranged from 0 to 8, with a mean of 2 costs per subject. All 19 rewards were identified as applicable to their prenatal care experience by eight 1 or more subjects. However, 6 cost items among 22 possible choices were not chosen by any of the subjects. Cost items not chosen included not wanting the baby, missing an appointment to take care of sick family members, and four items relating to lack of care and understanding from health-care providers. Both personal rewards and costs were selected as applicable to the women'S prenatal-care experience. Eighty-five percent of subjects chose health of the baby and 60% chose maternal health as two of the five most important rewards. One mother commented, "I'm always worried and concerned. This is my first child. I'm reassured when I come. I'm healthy and can go home with a peaceful mind." Another woman said, "It makes me feel that when I deliver, the baby will have a better chance of being healthy without any problems."

Personal costs most frequently identified by subjects included not having money for prenatal care and not feeling disposed to come to the appointment. Fifty-five percent of the women selected not having money for prenatal care as a problem, although they were receiving prenatal care. One subject noted,

If I didn't have the health department to come to, then it would have taken a longer process. It probably would have taken one to two months longer because of medical assistance. I could come here right away.

Fatigue contributed to not feeling disposed to come to a prenatal appointment; this item was selected by 33% of the sample. One woman said, "Sometimes I'm tired, and everybody naturally hates going to the doctor anyway. Today I didn't want to come. I was feeling tired." Another woman commented, "In my last few months, I just feel tired. I have to catch a bus and walk a ways."

The women perceived more family rewards than family costs as they sought prenatal care. The reward of a boyfriend or husband wanting a healthy baby was selected by 83% of the subjects and was among the top five rewards for 37.5% of the sample. Women commented on the caring and interest of their partners, for example, "There's a lot of women whose husbands or boyfriends don't care, and mine does. He always wants to know what happens when I go to the doctor." Another said, "It's important to know that my boyfriend is interested in the baby--that he's excited and wants to know more about it."

Family costs were selected less often than were personal or health-care-provider costs. Finding someone to take care of children was indicated as a problem by 13% of the sample.

For health-care-provider rewards, subjects chose availability and services of knowledgeable providers as important rewards. Among the five most important rewards, more than half (52.5%) selected having someone to talk to about problems, and 50% chose getting problems checked out. For example, one woman said, "If something's wrong, I tell them and they will check it out. There is someone there to help me out." Another subject emphasized the importance of prenatal health records: "They keep records on everything since you've been in the clinic. If I ask any question, they give me an answer. They tell if I want to know."

When asked what they wanted from prenatal care, women identified a number of rewards, including wanting information and advice about the pregnancy, honest explanations about problems, doctors and nurses to listen to them and spend time with them, and good treatment. The majority of women indicated that their prenatal-care providers were doing everything that they should do (92.5%) and were not performing unnecessary) procedures (90%).

The most frequently chosen health-care-provider costs included seeing someone different (28%) and feeling embarrassed by or not liking prenatal exams or tests (18%). One subject said: "I feel a need to bond with one of the midwives. They rotate. You get to see a little bit of everybody. I would like to get to know one better." Not all subjects viewed seeing someone different as a problem: "You do see a different doctor or nurse. It's not bad or anything. Each doctor has his own little way of helping out. One might answer another question."

FAMILY INFLUENCES

The majority of the women (82.5%) named one to three specific ways that family members influenced them, compared with 17.5% who responded that family members had no influence. Approximately one-half (52.5%) of the women stated that family members either wanted them to obtain care or told them to seek care. More than one-third (38%) noted that family members or their partners either came with them, brought them to appointments, or reminded them about appointments. Women also reported that family members thought prenatal care was a good idea, knew it was what the pregnant woman wanted to do, and expressed concern about the baby's and mother's health.

Many of the women's comments reflected the importance of feeling that family members cared about them. One said, "They asked about my weight because I have a hard time gaining weight--shows that they care." Another commented, "If I didn't [come], they would probably drag me down here and sit down and have a serious talk with me. They care."

Family correlates of prenatal care revealed only two important and significant correlations. Women who have more children were found to enter prenatal care later (r = .45, p

DISCUSSION

Exchange and choice theory, which interprets human actions from the perspective of rewards and costs, is a useful theoretical framework for studying women's use of prenatal care. Most prenatal-care research has been conducted from the perspective of barriers. Results of this study indicate that rewards or help from family members encourage women to obtain prenatal care by supporting and reinforcing the women'S perceptions of profit from prenatal care. Women make choices about seeking prenatal care within the context of their family life and the larger environment of the health-care system. Supportive family members positively influence women to obtain prenatal care and decrease the costs or problems they experience. The importance of partner response as a reward in obtaining prenatal care is indicated by the frequent choice of "boyfriend or husband wants a healthy baby."

An important study finding indicates that one-third of the women either didn't always feel disposed to come to prenatal appointments or felt too tired to keep their appointments. This prenatal-care cost could be reduced in a family environment that promotes prenatal care and assists women in getting to their appointments. The results indicate the importance of clinic personnel welcoming and encouraging family members' participation in prenatal-care visits. Family members who inquire about the health of the mother and the baby are likely to encourage women to continue with prenatal care. The selection of healthy baby and healthy mother among the five most important help items in prenatal care is consistent with the findings of other studies (Lia-Hoagberg et al., 1990; Patterson, Freese, & Goldenberg, 1990), which have found that the desire for a healthy pregnancy is an important motivating factor in obtaining prenatal care.

Women with children find that prenatal care is more costly or problematic than it is rewarding for several reasons: lack of transportation or child care, fatigue resulting from caring for young children, and perceived adequacy of knowledge about pregnancy. Supportive family members and caring health providers can decrease these costs for women with children. For example, in this study, the location and organization of the clinics reduced transportation and child-care problems. One of the clinics had a play area for children, and clinic staff sometimes watched children for women who brought children with them to appointments.

Although more than half of the sample identified not having money for care, the women had obtained services through health department clinics regardless of Medicaid eligibility status. This study underscores the importance of establishing government policies that provide prenatal care to low-income women. However, the availability of affordable prenatal care does not guarantee that low-income women will seek prenatal care. This study demonstrates that personal, family, and health-care-provider rewards and costs are present in a woman's environment and influence her perceptions of gain from prenatal care. For women in this study, health-care-provider rewards provided an added incentive to continue prenatal care. The health department clinics adapted prenatal-care service delivery to the needs of low-income women. In addition to the availability of low-cost care and convenience in location and schedule of clinic hours, services included the availability of interpreters, social workers, and nutritionists who were concerned about the needs of these pregnant women. A high percentage of the subjects mentioned that their health-care providers cared about them and listened to their problems. For low-income women who lack financial resources, especially those who lack social support, a caring prenatal-clinic environment is likely to increase the perception of gain from prenatal care.

Limitations of this study include the small sample size, conducting the interviews in a clinic setting, and the small number of family reward and cost items in the card-sort procedure. Thus, the findings cannot be generalized beyond this study. Locating the interviews in the clinic setting, although convenient, limited the sample to women who obtain prenatal care. Women who have chosen not to seek care are likely to experience more costs but also are more difficult to locate until after childbirth. Moreover, some subjects may have made positive comments about clinic personnel because the interviews took place in the clinic setting.

RECOMMENDATIONS

Practitioners who provide care for low-income pregnant women need to focus their efforts on interventions that are likely to make prenatal care a rewarding experience for women. Changes in prenatal-care policy have resulted in financially accessible care and increased convenience in clinic schedules and transportation. However, practitioners and policymakers should place greater emphasis on the contribution of family rewards and costs to women's prenatal-care choices.

Education for partners and family members of pregnant women should be provided in the clinic setting while women are seen by health-care providers. Education will increase family members' knowledge about the importance of prenatal care and offer suggestions about how to express concern and support to pregnant women. Incentives that encourage partners to accompany pregnant women to clinic visits should be built into a prenatal-care service delivery. Although partners are generally welcomed and included in prenatal visits, health-care providers rarely target partners or other family members for delivery of services. To reach women's partners before pregnancy occurs, education of the public through family life education programs and the media should target the men who father children. Informing these men about the importance of early prenatal care and how they can help their babies is likely to assist women in making good choices in seeking prenatal care. Women who already have children need to be targeted for additional interventions to encourage prenatal care. The provision of play areas and other amenities and services for mothers would likely increase attendance of these mothers.

Policymakers and health-care providers who develop prenatal-care programs for low-income women must be attuned to the special needs of this population. Although services to meet these needs may appear initially to increase financial costs, savings in future expenditures from the consequences of poor birth outcomes will be greater than the cost of an effective prenatal-care program. In addition to affordability, clinic location, and schedule factors, meeting the needs of low-income women can be accomplished through the availability of clinic personnel who understand the family and social environments of low-income pregnant women. Social workers and interpreters can provide comprehensive and collaborative service delivery. Clinics that serve low-income pregnant women should make a greater effort to improve consistency among health-care providers. A woman seen by the same health-care provider will be more likely to develop a caring, trusting relationship, which in turn will increase her perception of profit from prenatal care. Health-care providers should also implement strategies that reinforce and support the personal rewards women receive from prenatal care. These strategies include emphasizing the mother's and baby's health, giving decision-making control to the mother when it is feasible to do so, and encouraging self-care and self-knowledge about; the status of the pregnancy.

Further research is needed on the rewards and costs of inadequate prenatal care, family members' perspectives, and the interaction of personal, family, and provider factors. Studies of women who delay or avoid prenatal care could inform policymakers about rewarding strategies that enhance prenatal-care attendance for low-income women. An analysis of family members' perspectives may reveal strategies for strengthening the role family members play in encouraging prenatal care. A larger study that focuses specifically on the interaction of personal, family, and provider rewards and costs would help guide practitioners in choosing strategies that are rewarding for women.

Of course, providing financially feasible prenatal care to all will help reduce the overall costs of prenatal care for low-income women. However, the personal, family, and provider costs of obtaining prenatal care must be addressed if more women are to obtain adequate care. Providers and policymakers must become aware of these costs and offer services and develop programs that maximize the rewards of seeking prenatal care for low-income pregnant women.

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Marjorie A. Schaffer is Associate Professor, Department of Nursing, Bethel College, St. Paul, Minnesota. Betty Lia-Hoagberg is Associate Professor, School of Nursing, University of Minnesota, Minneapolis, Minnesota. The authors thank Karen Knoll for her assistance in arranging subject interviews.

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