Barriers to Seeking Prenatal Care

Barriers to Seeking Prenatal Care

Matt Dalstrom

Purpose What types of experiences do pregnant women have with

the medical system in Winnebago County? What prenatal services are available to pregnant women?

What is their perception of the availability and access to those services? How do they navigate the medical system? What barriers do they face?

What type, content, and source of social support is available to pregnant women? What, if any, perceived impact does it have on their pregnancy?

Are the medical and social experiences of African-American, Hispanic, and Caucasian mothers with LBW/premature pregnancies different than those with healthy pregnancies?

Recruitment 9 Organizations that provide prenatal

care or social services for women 14 Pregnant African-American women 6 Postpartum African-American women 8 Postpartum Caucasian women 1 Postpartum women

Overview: Longitudinal Interviews (N=14)

Yes No0

2

4

6

8

10

12

Was the Pregnancy Planned?

Yes No012345678

High-Risk Pregnancy

0369

OB/GYN Providers Used

Residence at Time of First Interview (N=14)

Overview: Postpartum (N=15)

0369

OB/GYN Providers Used

Yes No Missing0

2

4

6

8

High Risk

Yes No Missing02468101214

Was the Pregnancy Planned?

African-American 6Caucasian 8Hispanic 1

Postpartum Women’s Residence (N=15)*

* There are only eight addresses on the map because some women elected to not provide their addresses

Medical Providers and Caseworkers’

Perceptions (N=43)

During focus groups and interviews, medical providers and caseworkers discussed what they saw as barriers they face providing care and the reasons why women were noncompliant. In total, 43 people were interviewed from 9 organizations.

0

1

2

3

4

5

6

Number of Organizations that Expressed Theme

Barriers to Providing Care

Barriers to Providing Care: Medical Compliance

Women miss appointments, do not follow medical advice, and self-medicate (diagnosis and treat themselves). Makes it difficult to provide consistent care, provide medical information, and address acute/chronic health issues.


Providers mentioned that women have several detrimental sets of medical beliefs that impact compliance: Drug use beliefs:

Smoking marijuana helps the pregnancy Quitting smoking entirely is unhealthy

Contraceptive use beliefs: Believe that they are dangerous and/or do not know how

they work

Nutrition beliefs: Some women do not want to gain weight Varying beliefs about what is healthy

For example, drinking light colored soda is healthy or


Funding Five of the nine organizations complained that funding issues limited their

ability to provide services. These issues include having an increased caseload, a reduction in services offered, and/or a feeling that it is difficult to provide referral services. One caseworker mentioned,

“We have over eight hundred and something active prenatal patients, and you’re just seeing them one after another. And you wish you could spend so much time with them, and you want to, but sometimes you’ve got other patients you have to get to see. I wish we had seriously much more time because when I started here we would see the patients almost every single appointment, and we had enough time to do that, but we don’t have time to do that. Now that they’ve spread everything thin, it’s just harder to see a patient every time they came in. We try to see the ones that are high risk, but it’s just hard, and you have limited resources out there.”

Communication Communication entails the ability of the organization to get in contact with

the pregnant women via phone, mail, or in person. Many women move and have their phones cut off.


Educational Level/Health Literacy Women lack the knowledge of their body and

pregnancy to make informed decisions.

As one OB/GYN explained, “I will have girls come in and they do not

even understand parts of their body. So we need to start, depending on where they are coming from with just teaching, what is going on in their body. And the whole entire visit is focused around education.”

Medical Providers/Caseworker’s

Perceptions of the Barriers that Women Face Obtaining Prenatal Care

(N=43)

State of Crisis

Limited Social Support

Housing

Information Provided

Transportation

Emmotional State of Mother

Intergenerational Parenting Knowledge

Lack of Female Empowerment

Lack of Childcare

012345678

Number of Organizations that Expressed the Theme

Medical providers/caseworkers were also asked what they thought were the main reasons why women were not accessing prenatal services and what impacted their use.

Perceived Barriers

State of Crisis Women who are seen are in a state of crisis, meaning

that they have other pressing concerns aside from their pregnancy that impact their ability to access and use prenatal services. One physician explained the situation, “And regardless of their culture a lot of our patients are in a state of crisis. If you are borderline or are homeless, if you're a drug user or a drug pusher, or whatever…If you are in danger of being beat up or whatever, your pregnancy is not your first priority, you're just trying to survive.”

Limited Social Support Many women do not have friends or family to help them

with their pregnancy.

Perceived Barriers

Housing Women are housing insecure and/or live

in a dangerous neighborhood.

Transportation Ability to get to and from the medical

appointment.

Perceived Barriers

Intergenerational Parenting Knowledge Pregnant women tend to rely heavily on

their mothers, maternal grandmother, and aunts for information about their pregnancy, birth, nutrition, and for social/emotional support. This could result in women getting bad advise or in women not listening to their medical provider.

Women’s Perceptions 14 women were interviewed three times

during their pregnancy 15 women were interviewed after their

pregnancy They were asked to identify their

experiences with the medical system and also the reasons why they were non-complaint.

Negative Experiences with the Medical System (N=29)

0

4

8

12

16

20

Theme Frequency

During the longitudinal interviews, women were asked about problems they had with medical experiences.

Experiences Cont. Time

Women often complained of the time that it took to get an appointment, time they lost at work, time waiting in the doctor’s office, and travel time.

Delivery of Medical Information Many of the women did not read the materials given and felt that

the information was rushed. Some also felt that the doctors assumed that they knew things that they didn’t. In addition, many were not given any additional information.

Women complained that they did not get enough time with their provider.

Limited Access Only a few providers in town accept the medical card and it is

hard to identify them. Also there are limited medical options before one becomes pregnant.

Because of their prior problems getting appointments in Crusader, some women assumed the wait time would be the same for pregnancy.

Experiences Cont. Transportation

Women mentioned that the medical services were far away and the bus system did not take them where they wanted to go. Some were afraid of public transportation. Others mentioned the burden that asking for rides placed on their social network.

Patient/Provider Interaction Women generally wanted to spend more time with their

doctor, but the visits often felt rushed and they felt like they were not able to ask all of their questions. Also they believed that medical providers were giving them pamphlets because they did not have time to talk with them.

Experiences Cont. Using the Medical Card

About half of the women did not know how the medical card worked (co-pays, providers, eligibility)

Also some postponed care until they received a temporary or permanent card because they were afraid to pay the cost of care.

Instead they used the medical card

Knowledge Gaps A woman’s complaint about not knowing what to do before she obtained a

medical card. “Yes. I couldn’t go to the doctor or anything. It was very frustrating

for me. I’m like, “Oh my god, I can’t do anything.” The pregnancy center, they recommended me to come here [WCHD] …because I did not know about anything. No one would help me with nothing.”

A woman’s complaint about how pregnancy information was delivered to her after she found out that she was pregnant. “Like the first folder I got, oh my God, there are so many pamphlets in

there. You just get tired of looking at it and it’s like, I don’t even want to know. If the doctors wasn’t double booked, maybe they’d have the time in the room to tell me some of this information because even if it doesn’t come up, what if I come to a question, now I’m not in the room with you…Now, I don’t know - by the time the next appointment comes, you have pregnancy brain, at least I did, you probably forgot what it was you wanted to ask. It’s just like there’s has to be a better way to do this. I shouldn’t have to go home and play doctor.”

Experiences Cont. Women also mentioned that it was hard to use a medical

card because they were not told how to use it. “The Blue Cross Blue Shield is very easy to

navigate. You get your book at the beginning. You can request to have the provider books sent to you at any time. You can always go online to see if your doctor is in or out the network. All of that, it’s laid out. I still haven’t figured out this medical card. That’s what I got - I’m going to go online, that was plan, so I can find out how do I find out which doctors I can and cannot see, who is in and out of network, is there a listing. I have no clue….They just kind of throw the card to you [Laughter] and you’re out the door.”

Non-Compliance (N=29)

0

5

10

15

20

25

30

Theme Frequency

Women were also asked what prevented them from following medical advice.

Non-Compliance Cont.

Stress The stress that a woman has impacts her ability to focus primarily

on the pregnancy and has negative health effects.

Limited Social Support Many of the women complain that they were all alone, had to be

responsible for everything. This made it difficult to care for children, make medical appointments, handle household activities, and to have financial security. Furthermore many women complained that they did not have someone to talk to.

Father of the Baby If the father is present and willing to help, he can assist with

transportation and help around the house. However, many are not present, and are described as “immature,” “childlike” and in the minds of the women require as much supervision as their other children.


Medical Beliefs: Can be divided into perceptions of the quality of care, the beliefs surrounding care, and the level of health literacy that women have. Quality of treatment

“I went in with the medical card and it was even worse. It was like you’re looked at, unless you go to like a Crusader or a health department, it’s like you’re looked down on. You can tell – I don’t know how to describe it. It’s just a different feeling you get from the doctor and the nurses. You don’t feel cared for.”-(Pregnant woman)

Alternate view points Women have conflicting beliefs surrounding contraceptives and safe sex.

Many are distrustful of them and believe that there is a high instance of side effects. Also many do not know how to use them correctly.

Treatments/Medicines: Sometimes women do not believe that the medical advice that they are given is good. This is exacerbated when they get conflicting information from parents and friends, and when they do not have a strong relationship with their medical provider.


Medical beliefs also impact their continued drug use. For instance one women said that her friend,

“Couldn’t drink anything and I mean this is well off into the pregnancy. She just – it was like she was dying. Every time she got pregnant, she made the decision on her own to start smoking pot. And that was the only way she was able to eat. She started picking up weight and she felt better. She was like, “I feel bad for doing it.” She was like, “But this child is going to kill me.” Or the child is going to die because she couldn’t eat. She did start smoking the marijuana and she was fine and she has two children. She

had to end up doing it with her second one as well.


Many of the women mentioned how little they know/knew about pregnancy and their body. In many cases women did not know that they were pregnant, delay care and engage in risky behavior. 79% of the pregnancies were unplanned and only one received care in the first 9 weeks. One woman did not receive care until 7 months. “I was really sick and woozy. I did not have medical, so I could not

go to a clinic or anything. I ended up having a pregnancy test there and they told me it came in positive, and they asked me did I want an ultrasound. I did not believe them, I was like, “I am not pregnant”. They gave me ultrasound about two weeks later, and they told me according to the ultrasound, measuring the baby’s head, three months pregnant. Yeah, so I was shocked.”

“I was drinking a lot. By the time I did find out I was pregnant, I knew in the back of my mind it’s too late because I’ve done way too much and I got into my fourth month and that’s when I miscarried.”

This is very important because almost all of the women changed their behavior afterwards.


Housing: Women often complained that they had housing problems. This make is difficult to maintain contact and limited their control over the household (e.g. exposure to cigarette smoke).As one woman explained,

“I was moving to different places, they were sending my medical - when I finally got it in April, they were trying to send my medical card to me, and everyplace I went to they would say return to sender. My case worker told me that every time we send a card out to you, they are going to return it back saying “return to sender.”

Finances: Women also frequently complained about the cost associated with medical care.

As one woman explained, “For the medical, some people can’t afford a lot of

their medication and stuff, people who are struggling with their rent and stuff, at least give them like a little more time to get their appointments and stuff together. And to let people know what the medical covers or what doesn’t the medical cover. Give papers to let people know what changes are going to be made instead of people going to doctor’s appointments and then them ending up having to pay and don’t know it. And then they get stuck with the bill.”

Gaps in the System

Because of the chaotic nature of many of the women’s lives they: Do not utilize or do not know how to

utilize all the social services available

Find out that they are pregnant in a wide variety of ways and therefore enter the medical system at different locations and points in time

Do not have the resources (time, money, transportation, access) to implement medical provider recommendations

Have to rely heavily upon maternal relatives for financial and educational support

How do they Navigate the System?

In order to find out what social services are available, women rely on their social network. However, when women become pregnant

there is a tendency for their social network to become constrained.

Therefore their maternal relatives become the biggest source of information and financial and emotional support.

Sources of Information (N=22)

SourceFrequency (%)

Mom 65Doctor 50Friend 40Maternal grandmother 35Sister 25Internet 20Phone application 15

So where do women go for their knowledge of pregnancy and diagnosis of pregnancy problems?

What Do Women Want?

Easier appointments Less travel time (ability to condense medical

appointments to a single day) More time with their doctor/medical provider Ability to change medical provider Snacks in the waiting room Link the health department more closely with public

aid Information on social services and how to use the

medical card Don’t assume that they know the information Continue and extend social support

Expanding Social Support:

Providing a social support system: “She was there a lot for me [nurse at the

WCHD]. When I didn’t have no one to talk to me and she would give me advice and stuff about other stuff, too.”

“She was a sweetheart. That was the other part, they were women so I knew they understood what I was going through and both of these women have had miscarriages. They actually took the time to sit down and they talked and as I was crying, they hugged me. I felt human.”

Potential Interventions for Strategic Plan

Standardize sex education courses and evaluate health literacy

Media campaign Improve information pertaining to preconception and

maternal health. Advertise social services and address detrimental

health beliefs. Make information on social services and prenatal care

available online.

Educate family members, not just pregnant women.

Barriers to Seeking Prenatal Care

Documents

Transcript of Barriers to Seeking Prenatal Care