Many low-income women do not seek timely or adequate prenatal care, even when their health plan provides services covered by Medicaid. Half of Medicaid recipients who were enrolled in a managed care program in Tennessee and who were pregnant or gave birth in 1996-1997 sought no care during their first trimester; likewise, half made too few prenatal visits, as measured by a standard index of care. Although most women understood the value of prenatal care, personal circumstances such as fatigue and a lack of support from their baby's father often kept them from seeking services.1

Researchers interviewed 200 Medicaid recipients to explore factors related to the timing and adequacy of the prenatal care they sought once enrolled in the managed care plan. The investigators considered care early, or timely, if it began during the first trimester; they classified it as adequate if the woman had made at least 80% of the expected number of visits. Using chi-square and multiple regression analyses, they examined the associations between these measures of prenatal care and three types of barriers that may prevent women from seeking services: socioeconomic, system-related and personal.

Survey participants were predominantly black, unmarried and younger than 25; the majority had at most a high school education. Half were employed, and the same proportion were poor, but few lived in crowded conditions. In general, the women had enrolled in the program after becoming pregnant; reports of system-related obstacles to seeking care (such as child care or transportation difficulties, inconvenient clinic hours, inability to get time off from work or worries about cost) were uncommon. For slightly more than half the women, this pregnancy was their first; for about three-quarters, it had not been intended. Fewer than one-quarter said they were too tired to make prenatal care visits or reported feeling like a failure; the majority received help from their baby's father or their family.

In all, 47% of women had initiated prenatal care early, and 49% had made an adequate number of visits. At the bivariate level, no socioeconomic factors were significantly associated with the timing or adequacy of care. Several system-related factors, however, differed according to participants' level of prenatal care: Women who had initiated care late were about twice as likely as those who had sought services early to have enrolled in the plan after their first trimester (39% vs. 18%) and to have considered the clinic hours inconvenient (27% vs. 14%). Similarly, 24% of participants who had received inadequate care reported child care problems, compared with 12% of women who had made at least the recommended number of visits.

Personal factors also were significantly related to prenatal care at the bivariate level. Some 31% of women who had delayed seeking services complained of fatigue, compared with only 16% of those who had started receiving care early; 21% and 9%, respectively, considered themselves failures. The differential in the proportions reporting physical violence during their pregnancy was even sharper: 17% of women who had initiated care late, compared with 5% of those who had had timely care. Women who had made an inadequate number of prenatal care visits were more likely than those who had had adequate care to say that their pregnancy was unwanted (53% vs. 30%), that they were too tired to visit their provider (31% vs. 16%) and that they received little or no help from their baby's father (40% vs. 18%).

Results of the regression analyses, which controlled for age and for factors that were significant at the bivariate level, indicated that women who had experienced violence during pregnancy were almost four times as likely as others to delay care until after the first trimester (odds ratio, 3.5). Women who had enrolled in the health plan after becoming pregnant and those who reported being too tired to seek care also had an increased likelihood of delaying care (odds ratios, 2.4 and 2.2, respectively). Only one factor was predictive of adequacy of care: Women who received help from their infant's father were twice as likely as others to make fewer than the recommended number of visits (odds ratio, 1.9).

Overall, 89% of participants had a generally favorable attitude toward prenatal care. Virtually all of the women (95-98%) recognized the importance of going to every scheduled visit and understood the benefits of prenatal care; 80% reported that they would be more likely to seek services if they had a better understanding of how prenatal care would affect their own and their baby's health.

Given that women have positive attitudes toward prenatal care yet fail to take full advantage of available benefits, the investigators suggest that managed care plans collaborate with agencies that work with traditionally underserved populations to educate women in these populations about the prenatal benefits available to them, and to encourage women to take advantage of these benefits in a timely manner.--D. Hollander


1. Gazmararian JA et al., Prenatal care for low-income women enrolled in a managed-care organization, Obstetrics & Gynecology, 1999, 94(2):177-184.