Date of Defense:
April 20, 2018
In Minnesota, African American and American Indian babies are approximately 2 to 2.5 times more likely to pass away during their first year of life.1 Minnesota continues to work towards closing racial disparities in infant mortality and reducing their overall infant mortality rate. One major factor to consider in this issue is to eliminate disparities in poor prenatal outcomes. Barriers to prenatal care are critical to examine because early and adequate prenatal care are strongly associated with decreased risk of pre-term labor and low-birth weight.2 Low birth weight and premature infants have a significantly higher rate of dying before their first birthday compared to babies who were born average weight (>2,500g) and after 37-week gestation.3 Unfortunately, prematurity is the leading cause of infant mortality for African Americans and the third leading cause for American Indians.3 A significant public health goal is to reduce and close the disparity gap in infant mortality because this serves as an important indicator of the overall health and well-being of our population.
The primary objective of my field experience was to utilize and advance my knowledge, skills, and experience in policy research, analysis, and development. My role was to research and develop a white paper on the barriers women face in accessing and maintaining adequate prenatal care, and in particular, the barriers that exist among American Indian and African American women. My learning objectives were to: 1) Understand the role of legislation in maternal and child health policy; 2) Conduct a literature review; 3) Gain experience in compiling data from state and national sources, and literature to produce a comprehensive description of a public health issue facing the state; and 4) Develop a more extensive understanding of the roles and limitations the state health department has in maternal and child health policy, program development, and implementation.
The field experience involved analyzing and summarizing existing literature and quantitative data from public sources. The literature search included research journal articles produced in the United States between 2006 and 2016. Quantitative data were taken from the Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) and National Vital Statistic System.
The field experience took place at the Minnesota Department of Health in the Maternal and Child Health (MCH) Section from June 2016 to December 2016. With a focus on children, youth, women, and their families, the MCH Section’s mission is to “provide statewide leadership and public health information essential for promoting, improving or maintaining the health and well-being of women, children and families throughout Minnesota.”4 The field experience aligned well with the organization’s mission by assessing the barriers to meeting the health needs of pregnant women and, in doing so, utilizing the information to advocate for programs, policies, and funding to improve the health of the MCH population and address health disparities.
The literature review covering the period of 2006 to 2016 highlighted specific barriers to accessing and maintaining adequate prenatal care among African American women, American Indian women and low socioeconomic women. The barriers reported by the targeted population include, but are not limited to the following: depression,5-8 current substance use,5,9 unplanned or unwanted pregnancies,5-7,9-12 poverty or lack of financial means,5, 8-10,12 desire for more transparency and communication in prenatal care,5,11 lack of relationship with providers,10,11 perceived insignificance of prenatal care due to lengthy wait time and short visit time,5-7,10 transportation issues,5-7,9-12 inflexible work schedule,5,12 no health insurance,8,11,12 and navigating the system.10,11
Analyses of the Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) survey from 2009 to 2013, showed that the barriers reported vary by racial groups. American India women were more likely (per percentage) to report: 1) having too many other things going on; 2) not having Medicaid or MinnesotaCare: 3) not having transportation; 4) not having enough money; 5) being unable get an appointment when wanted; 6) not knowing they were pregnant; and 7) not wanting anyone to know they were pregnant. African American and Hispanic women had a higher percentage (approximately 47%) of women reporting that they did not seek prenatal care at a time that they wanted because they did not know they were pregnant.
The most important lessons I learned from the field experience were how to identify a public health issue, collect relevant information, and use the synthesized information to effectively develop and advocate for policy. The challenge I foresee is finding the right individuals and organizations to build momentum around this issue. Additionally, I learned that effective policy development requires inclusion of representative stakeholders in order to better understand and incorporate greater perspectives. Inclusion of representative stakeholders will be challenging, but it will increase the likelihood of a policy being successful in the implementation phase and meeting the needs of the targeted population.
1. Conduct focus groups to further assess reported barriers and identify culturally centered solutions to prenatal care access and maintenance in American Indian and African American communities
The literature review and Minnesota PRAMS data indicated several barriers to accessing and maintaining prenatal care. Conducting focus groups will inform potential solutions to address these barriers to prenatal care.
2. Expand the use of other prenatal care models in healthcare that address barriers to prenatal care
Traditionally, individual prenatal care is the standard of practice. Another model of care is group prenatal care (GPNC). GPNC combines prenatal medical care with prenatal education in a group setting. Although research is limited, some studies have shown participants in group prenatal care have babies with increased birth weight and/or gestational age compared to individual prenatal care patients.13 Furthermore, GPNC may address some of the barriers to maintaining adequate prenatal care reported by low socioeconomic women of color such as a more productive use of time and improved supportive relationship with providers and group members.14
The percentage of American Indian and African American women receiving early and adequate prenatal care is decreasing. The most recent data shows the disparities continue to worsen. However, with a better understanding of the barriers that hinders early and adequate prenatal care, we can move towards creating more effective policies and system changes to better serve the communities. These changes can reduce disparities in early access and adequate prenatal care.
1 United Health Foundation. America’s health ranking: 2015 report [internet]. [updated 2018; cited 2018 Apr 3]. Available from: https://www.americashealthrankings.org/explore/2015-annual-report/measure/IMR/state/MN
2 Tayebi T, Zahrani ST, & Mohammadpour R. Relationship between adequacy of prenatal care utilization index and pregnancy outcomes. Iran J Nursing Midwifery Research. 2013 Sept-Oct [cited 2016 Oct]; 18(5): pg. 360-366.
3 Minnesota Department of Health (MDH). Infant mortality reduction plan for Minnesota (Part One). Saint Paul: Commissioner’s Office; March 2015.
4 Minnesota Department of Health (MDH). Maternal and Child Health Section [Internet]. [updated unk; cited 2018 Mar 15]. Available from: http://www.health.state.mn.us/divs/cfh/program/mch/
5 Hanson JD, Understanding prenatal health care for American Indian women in a Northern Plains Tribe. J Transcult Nurs. 2012; 23(1): 29-37.
6 Torres R. Access barriers to prenatal care in emerging adult Latinas. Hisp Hlth Care Intern. 2016; 14(1):10-16.
7 Daniels P, Noe GF, Mayberry R. Barriers to prenatal care among Blacks women of low socioeconomic status. Am J Hlt Behav. 2006; 30(2): 188-198.
8 Suni TS, Spears WD, Hook L, Castillo J, Torres C. Initiation of and barriers to prenatal care use among low-income women in San Antonio, Texas. MCH J. 2010; 14: 133-140.
9 Roberts SCM, Pies C. Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care. MCH J. 2011; 15: 333-341
10 Edmongs BT, Mogul M, Shea JA. Undestanding low-income African American women’s expectations, preferences, and priorities in prenatal care. 2015; 38(2): 149-157.
11 Meyer E, Hennink M, Rochat R, Julian Z, Pinto M, Zertuche AD, et al. Working towards safe motherhood: delays and barriers to prenatal care for women in rural and peri-urban areas of Georgia. MCH J. 2016; 20: 1358-1365.
12 Bromley E, Nunes A, Phipps MG. Disparities in pregnancy healthcare utilization between Hispanic and Non-Hispanic White women in Rhode Island. MCH J. 2012; 16: 1576-1582.
13 Thielen K. Exploring the Group Prenatal Care Model: A Critical Review of the Literature. J Perinatal Edu. 2012; 21(4): 209-218.
14 Novick G, Sadler LS, Knafl KA, Groce NE, Kennedy HP. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved. 2012; 23(2):589-603.