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Soc. Sci. Med. Vol. 30, No. 4, pp. 487-495, 1990 0277-9536/90 $3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright © 1990 Pergamon Press plc

BARRIERS A N D MOTIVATORS TO PRENATAL CARE AMONG LOW-INCOME WOMEN

BETTY LIA-HOAGBERG, l* PETER RODE, 2 CATHERINE J. SKOVHOLT, l CHARLES N. OBERG, 3 CYNTHIA BERG, 4 SARA MULLETT 5 and THOMAS CHOI 1

tUniversity of Minnesota, School of Public Health, Minneapolis, MN 55455, 2Urban Coalition of Minneapolis, MN 55415, 3Hennepin County Medical Center, Minneapolis, MN 55415, 4Center for Disease Control, Atlanta, GA 30333 and 5Minnesota Department of Health, Minneapolis, MN 55416, U.S.A.

Abstract--Substantial evidence exists which links prenatal care to improved birth outcomes. However, low-income and nonwhite women in the United States, who are at greatest risk for poor birth outcomes, continue to receive the poorest prenatal care. The purpose of this study was to identify and compare barriers and motivators to prenatal care among women who lived in low-income census tracts. The stratified sample included recently delivered white, black and American Indian women who received adequate, intermediate, and inadequate prenatal care. Interviews were conducted which focused primarily on the women's perceptions of problems in obtaining prenatal care and getting to appointments. Results indicated that women with inadequate care identified a greater number of barriers and perceived them as more severe. Psychosocial, structural, and socio-demographic factors were the major barriers, while the mother's beliefs and support from others were important motivators. The predictive power of selected barrier variables was examined by a regression analysis. These variables accounted for 50% of the variance in prenatal care use. The results affirm the complexity of prenatal care participation behavior among low-income women and the dominant influence of psychosocial factors. Comprehensive, coordinated and multidisciplinary outreach and services which address psychosocial and structural barriers are needed to improve prenatal care for low-income women.

Key words--prenatal care, low income women, barriers, psychosocial factors

INTRODUCTION

Prenatal care is a major factor in preventing low birth-weight and other adverse pregnancy outcomes [1-5]. Women with no prenatal care are three times more likely to have low birth-weight babies ( < 2500 g or 5.5 lb) than mothers with early and continuous prenatal care [6, 7]. Low birth-weight accounts for two-thirds of infant deaths during the first month of life and half of all infant deaths in the first year of life [8, 9]. Infants born at low birth-weight are also more likely to develop chronic and handicapping con- ditions [10]. Low-income and minority women (blacks, American Indian and others) are at greatest risk for delivery of a low birth-weight infant [11, 12]. Nat ional studies in the United States suggest that prenatal care provides greater benefits for infants born to this high-risk group than to low-risk groups [13-17].

Data from 1985 indicate that 76.2% of all United States infants were born to women who started prenatal care in the first 3 months of pregnancy [18]. However in 1986 a higher percentage of babies (6%) were born to mothers who received late or no prenatal care than in 1980 (5.1%) [19]. The proport ions of women with no care also varies strikingly by race. Third trimester or no prenatal care was reported for 5% of white mothers, 10% of black mothers, and 12.3% for American Indian mothers [18, 20]. These

*Address correspondence to: Betty Lia-Hoagberg, Division of Human Development and Nutrition, School of Public Health, Box 197 UMHC, University of Minnesota, Minneapolis, MN 55455, U.S.A.

rates have continued at the same level for the past 3 years [20-23]. According to the Department of Health and Human Services, about 80% of females at high risk for having a low birth-weight infant could be identified at the first prenatal care visit and appropriate interventions could be taken [11]. How- ever, these women are also least likely to seek early and continuous prenatal care [23, 24].

Prenatal care not only saves infants' lives, it is also cost effective [25]. The Institute of Medicine report on low birth-weight indicates that every dollar spent on prenatal care for high-risk pregnant women saves U.S. $3.38 in medical care [26]. The Childrens' Defense Fund emphasizes that it costs about U.S. $600 to provide a pregnant women with comprehensive prenatal care services throughout her pregnancy, while the cost for neonatal intensive care is about U.S. $1000 per day [27]. The emotional costs of having a high-risk infant are more difficult to measure. However, research verifies both the emotional and economic stress on families of infants with significant medical impairment [28].

The high financial, social, and emotional costs of LBW make it imperative to understand the factors which prevent high-risk women from obtaining the care they need. Studies on medical, dental, mental health, and geriatric populations have identified three major categories of deterrents to health care, including structural, individual, and socio-demographic barriers [29]. Structural barriers include organization of services, availability of care, time, costs, and similar factors. Individual barriers are those related to the client/patient, such as knowledge, feelings, and attitudinal factors.

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488 BETTY LIA-HOAGBERG et al.

Recent studies of prenatal care services have also identified barriers which help explain why women obtain inadequate care. A structural factor, lack of financial resources or insurance coverage, has consistently emerged as the most critical barrier [30-35]. However recent research indicated that receipt of Medicaid (a public source of health care financing for low income individuals) does not insure use of prenatal care [36]. An estimated 26% 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 health insurance at all [37]. Other significant barriers associated with reduced prenatal care participation were inadequate access to transportation and child care [30]. Individual factors identified as important barriers included fear and delay in disclosing the pregnancy, fear of medical procedures, feeling that prenatal care was unimportant, and the presence of multiple personal and family problems [38-40]. Socio-demographic factors, including maternal age, marital status, financial status, educational level, and parity have also been associated with level of prenatal care [30-32]. Vital statistics have consistently documented the major differences among racial groups in prenatal care use. However, few studies have systematically sampled women from specific racial backgrounds by level of prenatal care. In addition, there has been a lack of emphasis on women's perceptions of their prenatal care [18].

While studies have focused on barriers to prenatal care, very little is known about motivators. The existing motivation literature includes limited information on factors that encourage or support prenatal care use [41-44].

The purpose of the study was to identify and compare barriers and motivators associated with prenatal care use among three groups of low-income women: white, black, and American Indian. Barriers were defined as those factors, perceived and unperceived, which were associated with delays in start- ing care or with infrequent care. Motivators were those factors which encouraged mothers to obtain and continue prenatal care.

METHOD

The study was conducted with a stratified sample of recently delivered white, black and American Indian women who received adequate, intermediate and inadequate care. The stratification was designed to assure approximately equal representation of all nine subgroups (Table 1). The women were interviewed in one public and four private hospitals in a

Table 1. Study subjects

Care level

Race Adequate Intermediate Inadequate Total

White 25 24 18 67 (31.8%)

Black 24 23 28 75 (35.5%)

American Indian 16 26 27 69 (32.7%)

Total 65 73 73 211 (30.8%) (34.6%) (34.6%) (100%)

midwest city in the United States between October 1986 and June 1987. Hospitals which served pregnant, low-income women were selected as study sites. Participants were selected from 41 census tracts where at least 20% of residents were living at or below the poverty level according to the 1980 census. Subjects were sampled proportionately from each study hospital, based on the number of births from the selected low-income census tracts. In addition, women were sampled within each study hospital by race and by care level to reflect that institution's birth records from the previous year. Level of care was assessed using the modified Kessner Index, which combines trimester prenatal care was started and number of visits, and adjusts for gestational age at birth to determine level of care (see Appendix) [45]. Quality of care is not assessed by the Kessner Index.

Potential subjects were screened on a daily basis at the five hospitals to determine study eligibility. Sub- jects were interviewed following delivery by a trained interviewer of their own race and were paid for their participation. Ninety-five percent of the interviews were completed in the hospital and 5% were done at home within 2 weeks of the delivery. Data were obtained in a 50-min structured interview using a pretested questionnaire with items derived from a review of previous research and an expert panel of providers. The interview was pilot tested and reviewed by perinatal care providers for content validity.

The interview included sections on socio-demographic data, reproductive history, and structural and individual psychosocial factors related to prenatal care use. The structural section included questions on experiences with the health care system, transportation, child care, and finances. The individual psychosocial section focused on attitudes and feelings about the pregnancy and prenatal care. The interview included open-ended and forced-choice questions. Responses to open-ended questions were recorded in the subject's own words. Barriers to prenatal care were assessed with two different sets of questions. First, the women were asked if a particular factor (such as transportation) was a problem (barrier) for them in obtaining prenatal care. Then additional questions were asked to assess if these same factors were reasons for the women to miss prenatal appointments. Demographic data and information on prenatal care participation were gathered from the medical record. After a content analysis was done, responses were scored by two independent raters with extensive experience in the perinatal health field. Scoring discrepancies were minimal and decisions on discrepancies were reached by discussion and mutual agreement between raters. If a consensus on scoring was not reached between raters, the item was deleted from analysis.

Of the 242 women contacted who met study cri- teria, 211 (87%) agreed to participate and 31 (13%) declined. Analysis of participants and nonpartici- pants indicated no significant differences on age, marital status, education or income level. The study was designed to include women in each care level, with equal representation from the three racial groups. Final study participants included 67 white, 75 black, and 69 American Indian women (Table 1). The

Barriers and motivators to p r e n a t a l care

Table 2. Socio-demographic factors by level of care

489

Adequate Intermediate Inadequate (n = 65) (n = 73) (n = 73) Total

Chi-square n (%) n (%) n (%) n (%) significance

Mother's age <20yr 7 (11) 18 20+ yr 57 (89) 55

Marital status Never married 33 (51) 47 Married 23 (35) 15 Separated/divorced 9 (14) 10

Educational status <Grade 12 20 (33) 34 HS graduate/GED 15 (25) 13 > 12 yr 25 (42) 23

Income <U.S. $10,000 43 (64) 52 ~>U.S. $10,000 20 (32) 20

Financial support during pregnancy General assistance (GA)/

aid to families with dependent children (AFDC) 32 (49) 51

No assistance 33 (51) 22

Employment status Employed 31 (48) 20 Unemployed/homemaker 25 (39) 43 Student 8 (13) 7

Live births I 2 52 (80) 49 3 + 13 (20) 24

Children at home to care for during pregnancy 0 29 (45) 33 1 + 36 (55) 40

(25) 22 (30) 47 (22) 7.57* (75) 51 (70) 163 (78)

(65) 56 (65) 136 (65) 3.32t (21) 8 (11) 46 (22) (14) 8 (11) 27 (13)

(49) 35 (54) 89 (46) 2.73* (19) 20 (31) 48 (25) (33) 10 (15) 58 (30)

(72) 58 (83) 153 (75) 4.08NS (28) 12 (11) 52 (25)

(70) 55 (75) 138 (65) 11.34t (30) 18 (25) 73 (35)

(29) 21 (29) 72 (35) 9.64* (61) 45 (63) 113 (55) (10) 6 (8) 21 (10)

(67) 41 (56) 142 (67) 8.88* (33) 32 (44) 69 (33)

(44) 20 (27) 82 (39) 5.90 NS (56) 53 (73) 129 (61)

*P < 0.05; t P < 0.01.

women in the inadequate care group who obtained no care included 4 white, 4 black, and 3 American Indian women.

Selected demographic characteristics of participants indicated that the majority of women were in their early twenties, 46% had less than high school education, and 65% were never married (Table 2). One-third (35%) of the women worked outside the home for at least part of the pregnancy, mostly in low-wage, low-benefit jobs such as waitress, clerical, and sales work. Another 10% were students for at least part of their pregnancy.

Several important demographic differences by racial group were identified. The majority (73%) of black and American Indian women had never been married, in contrast to 48% of the white women. Sixty-five percent of American Indian women had not graduated from high school, compared to 38% of black women and 32% of white women. Household income levels were also lowest for American Indians with 81% reporting income of less than U.S. $10,000 per year. In comparison, 74% of black women and 70% of white women reported similar incomes. One half of the white women were employed during part of their pregnancy, in contrast to 41% of black women and only 16% of American Indian women.

Data were analyzed initially by Chi-square tests, followed by a series of one way analysis of variance across three care levels and three racial groups. Selected variables were factor analyzed and made into scales. These scales, as well as single item vari-

ables, were used in multiple regression to assess their relative effects on amount of prenatal care.

RESULTS

Socio-demographic, structural, and individual/ psychosocial factors differed significantly among low- income women receiving various levels of care. Women with inadequate care differed from those with adequate and intermediate levels of care by the frequency and perceived severity of the barriers. However, there were few differences for barriers to prenatal care among the low-income white, black and American Indian groups. Poverty and its associated factors appears to exert a greater influence than race on prenatal care participation among low-income women. Variations in motivators were also identified among the care level groups. The findings will focus on level of care differences with mention of ethnic variations when significant.

Barriers to prenatal care Socio-demographic factors. Socio-demographic

factors were related to prenatal care use (Table 2). The majority of women were living in poverty: 75% had yearly household incomes of less than U.S. $10,000. Sixty-five percent of the study women received financial support from governmental (public) assistance [either Aid to Families with Dependent Children (AFDC) or state sponsored general assistance] programs. Women with inadequate prenatal care were significantly more likely to be under age 20


Table 3. Structural barriers by level of care

Barrier (problem in obtaining prenatal care)

Adequate Intermediate Inadequate Total

n (%) n (%) n (%) n (%) Chi-square significance

Paying for prenatal care 6 (9) 9 (12) 9 (13) 24 (12)

Public assistance (Medicaid) as source of payment for prenatal care 38 (59) 52 (73) 53 (73) 144 (68)

Child care* 4 (11) l0 (25) 19 (41) 33 (26) Transportation 14 (22) 20 (28) 27 (47) 61 (32)

0.50 NS

4.15 NS 9.46t 8.92~

*Based only on women with child care responsibilities during this pregnancy. tP < 0.01; ~P <0.05.

(P = 0.0227), to be unmarried (P = 0.009), less likely to be a high school graduate (P =0.0012), more frequently unemployed (P = 0.0093) and have more children (P = 0.0018).

Structural factors. Financial factors were not identified as a major barrier to prenatal care for the majority of poor women in this survey. Only 12% of the women said that paying for prenatal care was a major or moderate problem. There was no significant difference in problems paying for care between women with adequate and those with inadequate prenatal care (Table 3). The majority (68%) of the study women used Medicaid to pay for all or part of their prenatal care. Another 22% used private insurance and 10% were self-pay. Only 15 women said that worry about being able to pay for care led them to delay going for care. However, the results indicated that receipt of Medicaid did not insure that women would obtain early and regular prenatal care.

Child care was identified as a major barrier to prenatal care by 26% of the 129 women who had children at home during their pregnancy. Women with inadequate prenatal care (45%) were significantly more likely (P = 0.0001) to miss appointments due to child care problems than women with adequate (5.3%) or intermediate care (13%). Trans- portation problems were closely tied to child care problems (r = 0.49). If a woman had child care problems, she was also very likely to have transportation problems. This suggested that the combination of having children to care for and poor access to transportation are associated with inadequate prenatal care use.

Transportation was identified as a problem in getting care by 32% of the study women. In addition, 26% (44) of the women reported they missed prenatal care appointments because of transportation problems. This problem was identified significantly more often (P = 0.0019) by women with inadequate care (44%) than by women with intermediate (19%) or adequate care (17%). More than 70% of the women interviewed did not own cars and had to rely on others to drive them to appointments, take the bus or walk.

Forty-six percent (28) of the 61 women who reported transportation problems indicated that the cost of transportation was the major problem. Several differences were found among the racial groups. Sixty percent of white women had access to their own car or could borrow a car. Black women (42%) more often relied on someone to drive them to appointments. Approximately one-third of the Am-

erican Indian women walked to the Indian Health Board care site which is located in their neighbor- hood.

Individual /psychosocial factors. Women identified several individual and psychosocial factors which they perceived kept them from obtaining prenatal care or keeping their appointments. Other psychosocial factors (unperceived) were also associated with level of prenatal care, although these factors were not specifically identified as barriers by the women. Ex- amples of these factors were the woman's consideration of abortion or her feelings about the pregnancy.

Lack of pregnancy planning and recognition of the pregnancy were important issues for the majority of women. Three-quarters (76%) of the study women indicated their pregnancy was unplanned (Table 4). Eighty-five percent of women with inadequate care reported their pregnancy was unplanned, compared to 72% of women with adequate care and 70% of women with intermediate care. Timing of pregnancy recognition differed significantly (P = 0.003) among the women by care level. Women with adequate and intermediate care recognized their pregnancy an average of 6 weeks from their last period, while women with inadequate care identified the pregnancy an average of 13.5 weeks. Eleven women commented that they were unsure they were pregnant because of irregular periods or stress in their lives. There were also significant differences (P = 0.0008) among the three groups of women for confirmation of pregnancy. The women from the adequate and the intermediate care groups had their pregnancy confirmed an average of 4 weeks after they thought they were pregnant, compared to women with inadequate care who had the pregnancy confirmed at an average of 7 weeks. Twenty-five (12%) women discussed their lack of recognizing the pregnancy or denial as a reason for not seeking prenatal care earlier.

Women's emotional response to their pregnancy also differed by care level. Over half of the women with adequate (64%) and with intermediate (53%) prenatal care reported being unhappy or ambivalent when they discovered they were pregnant. However, more than 75% of women with inadequate care reported being unhappy/ambivalent with their pregnancy. Black (65%) and American Indian (66%) women were significantly (P =0.0178) more often unhappy/ambivalent about their pregnancy than white women (45%). It is not surprising that lack of pregnancy planning, failure to recognize pregnancy symptoms, delay of pregnancy confirmation and unhappiness/ambivalence about the pregnancy were

Barriers and motivators to prenatal care 491

Table 4. Individual/psychosocial barriers by level of care

Barrier (problem Adequate Intermediate Inadequate Total in obtaining Chi-square prenatal care) n (%) n (%) n (%) n (%) significance

Unplanned pregnancy 46 (72) 51 (70) 62 (85) 154 (76) 5.25 NS Unhappy when

discovered pregnancy 29 (64) 39 (53) 54 (76) 122 (59) 13.85~: Considered abortion 9 (14) 21 (29) 30 (42) 60 (29) 13.38t Personal and/or

family problems 10 (15) 7 (10) 29 (40) 46 (22) 22.30~ Depression and/or

not feeling well 11 (17) 11 (15) 32 (44) 54 (26) 20.18§ Prenatal care perceived

as important but not as a priority 11 (17) 15 (21 ) 29 (43) 55 (27) 13.42t

History of seeing a doctor only when ill 14 (22) 20 (29) 33 (47) 67 (33) 9.79t

Negative feelings about seeing doctors 1 (2) 4 (6) 16 (22) 21 (10) 20.30:~

Dissatisfied with treatment by provider 1 (2) 9 (12) 9 (15) 19 (10) 9.40*

*P <0.05; "I'P < 0.01; ~P <0.001; §P < 0.0001.

related to inadequate prenatal care. The results suggest that many women may be denying or repressing the reality of an unplanned and often unwanted pregnancy. Seeking early prenatal care would only confirm and force them to confront what they did not want to recognize or acknowledge. Women discussed trying to deal with the reality of the pregnancy. Responses from four women with inadequate care indicated denial of the pregnancy. Comments included "I didn' t want to face being pregnant ," and "I didn ' t want to believe I was pregnant ."

The women also differed in their consideration of abort ion as a means of resolving the pregnancy. Women in the inadequate (42%) or intermediate (29%) care groups were significantly more likely to have considered an abort ion with this pregnancy than women with adequate care (14%; P = 0.0012). There may be a variety of reasons why women would delay prenatal care if they were considering an abortion. These might include denial and ambivalence about the pregnancy, explorat ion of other alternatives and weighing the consequences of a child in their life. It was a time when women were considering their options. Examples of women's comments included: " I needed time to decide what I was going to d o - - a b o r t i o n or not" ; " I had planned an abort ion first and then did not have enough money for it, then became discouraged"; and "I knew I was pregnant and I hadn ' t made up my mind if I would keep it or not ."

Personal and family problems also emerged as important issues that contributed to late or lack of prenatal care for many women. Overall, 22% of study women reported personal and family problems. How- ever, the presence of personal and family problems differed significantly by care level (P = 0.0001), with 40% of those with inadequate care reporting such problems, compared to 10% of women with intermediate care and 15% of women with adequate care. Women also reported that they missed prenatal care appointments because they needed time and energy to deal with personal or family problems. Women with inadequate care (45%) missed appointments significantly more (P = 0.0004) than women with adequate (16%) or intermediate care (21%). Subjects commented that these problems included sick children or

family illness. Women also indicated to the interview- ers that relationship problems with their boyfriend or husband caused them considerable stress. Several women commented "I was running from an abusive husband during this pregnancy," " M y ex-boyfriend would stop me from going in. I was abused by him," and " M y husband and I were not getting along and I felt real down about it." American Indian women (41%) were significantly more likely (P = 0.0128) to report missing prenatal care visits due to personal problems than white (18%) or black (24%) women.

Feelings of depression or not feeling well were identified as additional problems in getting care by 26% of the study women. Women with inadequate care (44%) were significantly more likely (P = 0.0001) to identify these problems than women with intermediate (15%) or adequate care (17%). These women also commented that not feeling well and depression contributed to missing appointments. Several women identified depression and morning sickness: " I had much depression, laziness, and tired- ness." Several other women mentioned physical problems which kept them from prenatal visits: " I had nausea and swelling in my legs and feet. I was just sick a lot ."

Almost all of the study women acknowledged that prenatal care was important. However, 27% said that feeling that prenatal care was important did not always encourage them to obtain early and regular prenatal care. Women with inadequate care (43%) were significantly more likely (P = 0.0012) to report that despite the recognition that prenatal care was important, they remained unmotivated to obtain adequate care. In contrast, 17% of women who received adequate care and 21% of those with intermediate care said that perceived importance of prenatal care was not a mot ivator to obtain care.

Differences in health care beliefs and behaviors were also identified among the groups. Women with inadequate care (47%) were significantly more likely (P = 0.0075) to obtain medical care only when they were ill, compared to those with adequate (22%) or intermediate (29%) care. The adequate care women also reported more negative feelings about going to the doctor than the other two groups. Twenty-two percent of those with inadequate care reported nega-


Table 5. Multiple regression: variables affecting level of prenatal care

Variable N Beta T Significance

Source of payment for prenatal care 190 -0 .05000 Child care access* 105 0.35011 Awareness of pregnancy symptoms 204 0.13405 Parity 211 0.16577 Importance of prenatal care

as a motivator 205 0.22914 Perceived treatment by provider 205 0.24188 Consideration of abortion 209 0.11807 Prior involvement with health

care system 204 0.21512 Mother 's age 210 0.21257 Constant

R 2 explained 0.5037

-0 .660 0.5109 3.871 0.0002 1.691 0.0947 1.815 0.0731

2.691 0.0086 2.943 0.0042 1.396 0.1665

2,417 0.0178 2,192 0.0312 2.066 0.0420

*Applies only to women who had child care responsibilities during this pregnancy.

tive feelings about going to the doctor compared to 6% of the intermediate groups and 2% of the adequate group (P = 0.0004). Factors contributing to negative feelings included fear of medical procedures, poor past experiences with provider, lack of contin- uity of care, and poor relationship with current provider. An additional issue was the women's perception of their treatment at the prenatal care facility during their pregnancy. Women with inadequate care (15%) were also significantly (P=0.0248) more likely to express feelings of dissatisfaction about their treatment by their prenatal care provider than women who received adequate (2%) or intermediate (12%) care.

Results o f regression analysis. Multiple regression was run with predesignated, theoretically relevant variables to test the relative predictiveness of each antecedent variable on prenatal care. Several significant variables, including transportation, were ex- cluded from the regression analysis due to problems with multi-collinearity. All of these antecedent variables and their betas are shown in Table 5. Access to child care was the best predictor (beta = 0.350), followed by the woman's perception of her treatment by her provider (beta = 0.242), and importance of prenatal care as a motivator to obtain care (beta = 0.229). Other significant predictors included the mother's prior involvement with the health care system (beta=0.215) and the mother's age (beta---0.215). In contrast to other research, source of payment for prenatal care was not a significant predictor among this particular sample of women when other significant variables were controlled. This is probably because of the homogeneous socio- economic background of this sample of women (68 % were Medicaid recipients). All of the above antecedent variables account for half (r2= 0.5037) the variance in prenatal care use.

Motivators and supports for prenatal care

Although much of the research has focused on barriers to prenatal care it is equally important to analyze those factors which women perceive as motivators or supports to obtain care. In addition to being questioned about problems in obtaining prenatal care, women in this study were also asked to identify reasons for getting prenatal care and measures which they perceived as supportive for continuing care.

The strongest motivating factor for getting prenatal care in all groups was the belief that prenatal

care would ensure a healthy baby. However, women with adequate (52%) and intermediate (47%) care chose that reason significantly more often (P = 0.0072) than women with inadequate care (27%). In contrast, among women with inadequate care the most frequently mentioned reasons given for obtaining prenatal care were because it was "the thing to do," or "I knew I was supposed to" (28%). Addi- tional reasons for getting prenatal care included concern for their own health (10%), fear of problems or complications with the pregnancy (7%), or en- couragement to do so by family and friends (11%).

The women also identified supports (persons and/or measures) which encouraged or helped them to obtain prenatal care. Sixty-nine percent of the study women reported that someone had encouraged them to seek prenatal care. White women (43%; who were more likely to be married) were significantly more likely (P = 0.0224) to have received encourage- ment from a significant male in their lives than were black (23%) or American Indian (35%) women. Black women (46%) more frequently reported that no one had encouraged them to seek prenatal care, in contrast to 25% of white women and 22% of American Indian women (P = 0.0030). Eighty-seven percent of the women indicated that someone helped them get to their prenatal appointments. Actions which were cited as helpful were receiving verbal support (34%), tides to appointments (33%), and provision of child care (20%).

Only 45% of the women reported that they received advice from anyone about how to care for themselves when they were pregnant. Of those who received advice, 56% received it from their mothers and 21% from their husband or boyfriend. Mothers were more frequently the advice-givers for black women (P=0.0217); males (husbands or boy- friends) were identified significantly more often by white women (P = 0.0446). The advice given to the women included eating well for themselves and their babies, not smoking or drinking, getting rest and relaxation, and getting prenatal care. While professional caregivers were not frequently mentioned as advice-givers, women with adequate care reported following advice offered by caregivers significantly more frequently (P = 0.05) than women with intermediate or inadequate care.

These data suggest that support and assistance from others is a significant and important motivator to obtain prenatal care for low-income women. It is

Barriers and motivators to prenatal care 493

disturbing to note that over half of the women perceived that they received no advice about their pregnancy from anyone, including providers, friends, relatives or others.

D I S C U S S I O N

The primary objective of the study was to identify perceived and unperceived barriers and motivators to prenatal care among low-income white, black, and American Indian women in the United States. The interviews revealed striking differences between women receiving inadequate care and those obtaining adequate or intermediate levels of care. There were few significant differences, however, in the barriers and motivators among the groups of white, black, and American Indian women. Generally, women from the three racial groups shared many of the same problems in obtaining care and were motivated to seek care for similar reasons.

The results suggest that structural, individual/ psychosocial, and socio-demographic factors are important barriers to prenatal care use among low- income women. In contrast to recently published studies [30, 31, 34], financial factors were not identified as major barriers to prenatal care for these women. This finding is probably due to the large number of women who were sufficiently poor to receive government-financed Medicaid. (Sixty-eight percent used Medicaid as a source of payment for prenatal care.) The results of this study are consistent with those of McDonald and Coburn [36] which found that access to Medicaid did not ensure adequate prenatal care. Rather, multiple noneconomic barriers remain after economic barriers are reduced. In other words, removal of financial barriers is necessary but not sufficient to ensure adequate prenatal care participation among low-income women.

While paying for care was not an obstacle for most women, the study found that barriers to care are often deeply rooted in the experience of being poor. The impact of poverty on the lives of these women cannot be underestimated. Three-quarters of the women participating in the study had incomes below the official poverty level, and all lived in poor neigh- borhoods. Three-quarters were single and two-thirds already had children to care for at home. Personal or family problems and feelings of depression were common stressors in their lives. The majority of women said they were not trying to become pregnant. Many reported experiencing feelings of ambivalence, unhappiness and even denial about the pregnancy. Of particular concern were the women with inadequate care, who were significantly more likely to be young, single, poorly educated, and unemployed. They were more likely to report the multiple, interrelated problems of stress, depression, child care, transportation, and other hassles of daily living. Being poor often leads people to feel that they have few options and little control over basic life decisions such as fertility and health. In the process of putting food on the table, caring for other children, coping with everyday stresses of being poor, and dealing with the worries engendered by the pregnancy, significant numbers of women found it difficult to give high priority to prenatal care.

The motivators to care may provide the most insightful findings of this study. The results suggest that even when a complex array of barriers are present, there are factors which can motivate a woman to seek care despite her difficulties. Encour- agement to seek and continue care from important people in the woman's life, whether it be a partner, a mother, a friend, or a professional can be a major motivator. While approx. 80% of the women indicated that someone encouraged them to seek care, less than half reported receiving advice from anyone about how to care for themselves during pregnancy. Once again, women with inadequate care were more likely to experience a lack of support from others. The fact that several women reported having no one they could talk to or could count on for support during their pregnancy indicates the additional isola- tion of some women.

The results of this study affirm the need for a comprehensive, multidisciplinary approach to prenatal care. It is clear that an initial and critical emphasis of prenatal care must be on the mother herself. When her needs and concerns are addressed, she may be more likely to focus on the needs of the fetus. It is unlikely that a woman will be concerned about good nutrition for optimal fetal development if she is faced with inadequate financial resources, is depressed and considering an abortion. In addition, the definition of prenatal care needs to be expanded and redefined to meet the needs of women being served. Especially among low-income women, thor- ough psychosocial assessment should be a high priority as well as routine medical care. Care must be comprehensive and flexible, and designed to meet the needs of individual women.

Community outreach and ongoing support are essential to identify and bring difficult-to-reach (such as inadequate care group) women into prenatal care. Women must be asked about problems (barriers) which keep them from obtaining care. The community outreach efforts should then be planned to address those barriers. Prenatal assessments should also identify supportive persons or measures which the women would find helpful.

The study findings document the complexity of prenatal care participation behavior. There is a need for further research to investigate the interventions, strategies and programs which promote low-income women's greater use of prenatal care.

The challenge to maternity care providers and policy makers is to make sure that each woman has the benefits of receiving prenatal care that addresses individual needs and concerns. Without an emphasis on the total life situation of low-income pregnant women, the prospects of improved prenatal care participation among low-income women are diminished.

Acknowledgements--This research was partially funded by BRSG S07 RR 055448, awarded by the Biomedical Research Support Grant Program, Division of Research and Resources, National Institutes of Health, and by the Minneapolis Foundation and Hennepin Faculty Associates of Minneapolis, Minnesota. Thanks go to Sheldon Swaney, Helen Kim and Karen Knoll of the Minneapolis Health Department, Minneapolis, Minnesota, for data entry and

SSM 30/~-H


consultation, to Kenyari Bellfield of the Minneapolis Urban Coalition for project assistance, and to Paul Walsh for typing this manuscript.

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