One in four low-income California women with third-party health insurance who gave birth in 1994-1995 did not obtain prenatal care during the first trimester. Researchers who interviewed more than 3,000 women about their attitudes, beliefs and perceptions found that logistical barriers played relatively little role in the failure to receive early care. However, in an analysis that controlled for the effects of a range of factors that might serve as barriers to prenatal care, women with an unwanted or unplanned pregnancy were roughly 35-40% more likely than those with a wanted pregnancy to have received no prenatal care in the first trimester. Additionally, those with no regular health care provider in the period before conception were nearly 40% more likely than women with a regular source of care, and those with no post-high school education were 40-70% more likely than those with a higher education, to have waited until the second trimester (or later) to initiate prenatal care.1

Despite wide societal agreement that women should begin prenatal care during the first trimester, many low-income women initiate prenatal care late or do not receive it at all. Lack of health insurance can be a serious barrier, but even women covered by Medicaid may fail to receive timely prenatal care. Past research has identified a range of other potential barriers to timely receipt of care (among them child care or transportation problems, a lack of appreciation for the importance of early prenatal care, negative attitudes about the pregnancy or personal stress), but consensus is lacking on which have the greatest impact.

To examine these issues, researchers utilized information collected from more than 10,000 women in California who delivered between August 1994 and July 1995. All were surveyed face-to-face shortly after giving birth at one of 19 randomly selected hospitals in the state. From this population, the investigators extracted data on 3,071 women who were aged 18 or older when interviewed, who had a family income that was no more than twice the federally designated poverty level and who were covered either by Medi-Cal (California's Medicaid program) or by private insurance both before becoming pregnant and during the pregnancy.

Prenatal care was considered timely if a woman made her initial visit during the first trimester; a later start was classified as untimely. The researchers examined differences in receipt of care according to a number of factors that might deter a woman from seeking services: seven social and demographic characteristics (such as age, income or ethnicity); 10 knowledge-related or attitudinal variables (among them knowledge of the importance of early care and planning status of the pregnancy); five stress-related factors (ranging from homelessness to preexisting health problems); and four logistical barriers (including transportation problems and child care difficulties).

Seventy percent of the women had 2-4 children, 65% had an income at or below the poverty level, 52% were covered by Medi-Cal, 36% had not completed high school and 49% were unmarried. Fifty-four percent were Hispanic, and the majority of these (37% overall) spoke only Spanish at home. Very few did not know the importance of prenatal care (3%) or doubted that prenatal care was important (4%), but 22% had no regular source of health care before the pregnancy. Sixty-six percent reported that the pregnancy was unplanned, and 43% said it was unwanted. Sixteen percent said their health was fair or poor before the pregnancy.

Twenty-eight percent of the women obtained either untimely prenatal care or none at all--39% of those covered by Medi-Cal and 16% of those who had private insurance. Six percent were not aware that they were pregnant until after the first trimester; thus, 22% knew that they were pregnant in the first trimester yet did not begin prenatal care then.

When the researchers controlled for the effects of a broad range of variables and restricted their analyses to women who knew during the first trimester that they were pregnant, they found that nine factors had a statistically significant impact on the likelihood of not beginning prenatal care in the first trimester. Women who had had five or more births were twice as likely as those having their first birth and women who did not know that prenatal care is important were twice as likely as those who did to have failed to initiate prenatal care in a timely way (odds ratio of 2.0 for each).

Education played an important role in receipt of prenatal care: Women who lacked a high school education and those who had only graduated from high school were 71% and 41% more likely than others not to have received early prenatal care (odds ratios of 1.7 and 1.4, respectively). Attitudes about the pregnancy were also major predictors: Those who feared disclosure of the pregnancy were 47% more likely to have missed out on timely care than those who did not; moreover, women with an unwanted pregnancy were 41% more likely and those with an unplanned pregnancy were 35% more likely than those with a planned pregnancy. Women with no regular source of health care before conception were 37% more likely than those with a regular health provider to have received untimely care. Finally, women who reported transportation problems were 68% more likely than those without such problems; however, only 8% of women reported experiencing transportation problems.

Characteristics often considered related to receipt of inadequate prenatal care (such as being unmarried, being black or Hispanic and being Spanish-speaking) were not significantly linked to untimely prenatal care once the effects of other factors were controlled for. The analysts suggest several explanations for this finding, among them the investigation's focus on timely care (as opposed to a composite measure of the adequacy of prenatal care) and on women already covered by health insurance.

The researchers also examined what characteristics predicted women's not knowing that they were pregnant during the first trimester. Women with an unplanned pregnancy (odds ratio of 2.7) and 18-19-year-olds (1.9) were significantly more likely than others to have been unaware; no other factors had a statistically significant effect.

The results, the investigators note, reveal important barriers to timely prenatal care that are mostly related to issues affecting women before pregnancy. "Logistic barriers during pregnancy, frequently cited in previous literature, appeared to play a relatively limited role in explaining untimely initiation of prenatal care," the researchers observe.

Substantial improvements in the receipt of early prenatal care among women such as those included in the study sample "are most likely to be accomplished through policies that focus on these women before they become pregnant," the researchers conclude. They argue that their analysis suggests the importance of "reducing barriers to effective family planning, increasing the proportions of nonpregnant women who have a regular source of health care, and reducing the disadvantages associated with lack of education beyond high school."--M. Klitsch


1. Braveman P et al., Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors, Obstetrics & Gynecology, 2000, 95(6):874-880.