Early prenatal care in urban black and white women

Impacto de las condiciones sociodemográficas sobre el control prenatal en Latinoamérica

Introducción. El control prenatal corresponde a una estrategia encaminada a prevenir las posibles complicaciones del embarazo, el parto y el puerperio. Diversos estudios aislados se han realizado para identificar factores que pueden afectar de forma negativa el control prenatal.Objetivo. Realizar una síntesis cualitativa de la literatura respecto al impacto de las condiciones sociodemográficas sobre el control prenatal en Latinoamérica.Materiales y métodos. Se realizó una búsqueda de la literatura a junio de 2018 en las bases de datos EBSCO, Embase, ScienceDirect, LILACS, SciELO, Cochrane Library, MEDLINE-PubMed y Google Scholar, con los términos “prenatal care” AND “Health services accessibility” AND “Pregnancy, Health services accessibility” AND “Pregnancy, prenatal care” AND “Health services accessibility” y sin límite de tiempo.Resultados. Se encontraron 13 artículos con información relevante para el desarrollo de la presente revisión.Conclusiones. La literatura disponible sugiere que condiciones sociodemográficas desfavorables podrían incidir de manera negativa sobre el control prenatal. El cuidado del hogar, la atención de otros hijos, la afiliación al sistema de seguridad social, la obligación laboral y el desempleo parecen ser los principales factores que afectan la calidad del mismo.

The association between ethnicity and late presentation to antenatal care among pregnant women living with HIV in the UK and Ireland

UK and Ireland guidelines state that all pregnant women should have their first antenatal care appointment by 13 weeks of pregnancy (antenatal booking). We present the results of an analysis looking at the association between maternal ethnicity and late antenatal booking in HIV-positive women in the UK and Ireland. We analysed data from the National Study of HIV in Pregnancy and Childhood (NSHPC). We included all pregnancies in women who were diagnosed with HIV before delivery and had an estimated delivery date between 1 January 2008 and 31 December 2009. Late booking was defined as antenatal booking at 13 weeks or later. The baseline reference group for all analyses comprised women of "white" ethnicity. Logistic regression models were fitted to estimate adjusted odds ratios (AOR). There were 2721 eligible reported pregnancies; 63% (1709) had data available on antenatal care booking date. In just over 50% of pregnancies (871/1709), the antenatal booking date was ≥13 weeks of pregnancy (i.e., late booking). Women diagnosed with HIV during the current pregnancy were more likely to present for antenatal care late than those previously diagnosed (59.1% vs. 47.5%, p<0.001). Where women knew their HIV status prior to becoming pregnant, the risk of late booking was raised for those of African ethnicity (AOR 1.80; 95% confidence interval (CI) 1.14, 2.82; p=0.011). In women diagnosed with HIV during pregnancy, the risk of late booking was also higher for women of African ethnicity (AOR 2.98: 95% CI 1.45, 6.11; p=0.003) and for women of other black ethnicity (AOR 3.74: 95% CI 1.28, 10.94; p=0.016). Overall, women of African or other black ethnicity were more likely to book late for antenatal care compared with white women, regardless of timing of diagnosis. This may have an adverse effect on maternal and infant outcomes, including mother-to-child transmission of HIV.

Social and ethnic differences in attendance for antenatal care in England

OBJECTIVES

Evidence about sociodemographic factors associated with late attendance for antenatal care in the UK is of poor quality. This study aimed to identify any social or ethnic differences in access to antenatal care, and to quantify the effect of any such differences using data collected in a survey of women's experiences of antenatal screening.

STUDY DESIGN

Cross-sectional survey using a postal questionnaire.

METHODS

A stratified clustered random sampling strategy was used. Hospitals in England were stratified according to ethnic mix. In order to ensure inclusion of an adequate number of women from Black and Minority Ethnic (BME) backgrounds, hospitals with >or= 15% of women of BME origin were oversampled. Pregnant women aged >or= 16 years, receiving care in 15 participating hospitals, were sent a postal questionnaire at 27-31 weeks of gestation. Logistic regression was used to estimate odds ratios (ORs) comparing social and ethnic groups for attendance for antenatal care, adjusting for sociodemographic and clinical factors.

RESULTS

In total, 839 women (57%) returned completed questionnaires. Compared with all women giving birth in 2005 in England and Wales, the survey sample contained fewer women aged <20 years (5.8% vs 6.9%), more women aged >35 years (24.1% vs 19.6%) and fewer women who were born outside the UK (14.8% vs 20.8%). Five percent of responders were late attenders for their first antenatal appointment. The odds of late initiation of antenatal care were higher for women born outside the UK [OR 4.37, 95% confidence interval (CI) 2.25-8.52; P=0.0004] and for women living without a husband/partner (OR 2.74, 95% CI 1.81-4.16; P=0.0002). In total, 2.5% of women were late attenders for their booking appointment. The odds of late booking were higher for Black women (OR 5.92, 95% CI 2.97-11.83) and women living without a husband/partner (OR 1.95, 95% CI 0.97-3.93; P=0.06).

CONCLUSIONS

A small proportion of women initiate and/or book late for antenatal care. This study provides recent, good-quality evidence that women born outside the UK and those living without a husband/partner may be at particular risk of late attendance for antenatal care.

Clinical, provider and sociodemographic predictors of late initiation of antenatal care in England and Wales

OBJECTIVE

To identify factors that are predictive of late initiation of antenatal care in England and Wales.

DESIGN

A multivariate binomial regression model was constructed to examine the association between clinical, provider and sociodemographic characteristics and late initiation of antenatal care.

SETTING

Nine maternity units in Northern England and North Wales.

POPULATION

A total of 20,771 women with a singleton pregnancy who delivered a liveborn or stillborn baby between 1 August 1994 and 31 July 1995. All analyses were based on the 17,765 (85.5%) women for whom information on gestational age at initial presentation for antenatal care and other variables incorporated into the regression model was retrievable from the case records.

RESULTS

Primiparous women of high obstetric risk were 13.4% more likely to initiate antenatal care after 10 weeks of gestation than a low risk reference group (adjusted OR 1.134, 95% CI 1.011, 1.272; P = 0.0312), and 34.3% more likely to initiate antenatal care after 18 weeks of gestation (adjusted OR 1.343, 95% CI 1.046, 1.724; P = 0.0208). This association between high obstetric risk status and late initiation of antenatal care was not replicated among multiparous women. When the effects of other independent variables on gestational age at booking were examined, the following characteristics were associated with failure to initiate antenatal care by 10 weeks of gestation (P < or = 0.05): maternal age at booking, smoking status, ethnicity, type of hospital at booking, the planned pattern of antenatal care and the planned place of delivery. Adopting a criterion of 18 weeks of gestation exacerbated the association between clinical and sociodemographic characteristics and late initiation of antenatal care, but appeared to dilute the association between provider characteristics and late initiation of antenatal care.

CONCLUSIONS

There is a pressing need for further research to identify the specific concerns of late bookers, to identify areas where new interventions might encourage the uptake of services and to gauge the likely impact of increased dissemination of information about the availability of antenatal care services.

Increasing access to prenatal care: an evaluation of minority health coalitions' early pregnancy project

Early prenatal care utilization is a problem for racial and ethnic minority women in Indiana. Minority health coalitions in Indiana developed early pregnancy care coordination projects to address this need. To evaluate project outcomes, birth certificates of infants born to project mothers were matched with birth certificates of infants whose mothers did not receive care coordination. Results showed that project mothers were significantly more likely to start prenatal care earlier, had better prenatal care utilization as measured by the Kessner Index (Kessner, Singer, Kalk, & Schlesinger, 1973), and had better adequacy of care as measured by the APNCU Index (Kotelchuck, 1994) than the noncare-coordinated mothers. Although the project was successful in meeting its primary objective, specific recommendations are made for community health nurses to partner with the coalitions in improving the content of prenatal care, decreasing sociocultural barriers to care, and assisting in the evaluation of outcomes of future projects.

Seeking early care: the role of prenatal care advocates

This exploratory study investigates the role of social support in the initiation of prenatal care by analyzing data from interviews with 36 pregnant women at a public health facility in Tuscaloosa, Alabama. A systematic sample of U.S.-born women aged 19 to 34 who initiated care in each of the three trimesters was interviewed. After controlling for age and education, three variables were found to be associated with earlier estimated gestational age at the time of a woman's first prenatal visit: self-referral to care, more prenatal care advocates, and fewer children. There was no significant effect on the timing of entry to care associated with ethnicity, marital status, transportation availability, rural vs. urban residence, distance of residence from the clinic, or prior prenatal care at the public health facility. These results suggest that first-time mothers are likely to seek early care and that family and friends play a significant support role in encouraging women to begin care.

Poor antenatal care in 20 French districts: risk factors and pregnancy outcome

STUDY OBJECTIVE

Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome.

DESIGN

All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years.

SETTING

20 French districts including 85,000 births from January to June 1993.

SUBJECTS

848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month.

MAIN RESULTS

1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight.

CONCLUSION

Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.

Utilisation of prenatal services and birth outcomes: a community-based study in Israel

The purpose of this paper was to assess several measures of utilisation of prenatal care as predictors of birth outcome in a community where the availability and quality of services were equal for all pregnant women. A case-control study was conducted in a small community in Israel, comparing 189 women whose pregnancy resulted in an unfavourable outcome (perinatal mortality, preterm birth and low birthweight at term) with 384 women, matched by birth order, who had a live, full-term infant weighing 2500 g or more. In a multivariable analysis, adjusting for pregnancy complications, maternal age, parity and socio-economic disadvantage, gestational age at initiation of prenatal care was not an independent predictor of unfavourable outcome; neither was lower than the recommended number of visits for the period under care. However, a higher than expected number of visits was associated with unfavourable outcome [odds ratio (OR) = 6.10, 95% CI 2.09-17.78], as was non-compliance with medical recommendations [OR = 2.02, 95% CI 1.24-3.29. The context of prenatal care delivery, as well as the process of care and compliance with recommendations, should be assessed in order to determine the impact of prenatal care on birth outcomes.

Denial of pregnancy: a review and case reports

This paper describes the characteristics of women who deny awareness of their pregnancies, the underlying causes and conflicts, and specific interventions required to address these issues. Case reports illustrate this complication of pregnancy. The absence of many physical symptoms of pregnancy, inexperience, general inattentiveness to bodily cues, intense psychological conflicts about the pregnancy, and external stresses can contribute to the denial in otherwise well-adjusted women. Assessment should include the possible contribution of painful reactivation of memories concerning childhood or adult trauma and the effect of dissociative states on the development of denial of pregnancy. Psychotherapy is recommended to resolve these conflicts, and to prevent future pregnancy denials and child abuse or neglect. Denial of pregnancy is easier to understand in women with psychosis or serious cognitive impairment than in those without such disorders. The underlying illness requires treatment by a psychiatrist. Psychological conflicts also exist in psychotic women, such as the intense wish to have a baby while fearing loss of the infant to child-protection services. Acknowledging the conflict and supporting the mother despite her puzzling behavior is an important task for health caregivers.

Prenatal peer counseling: an answer to the persistent difficulties with prenatal care for low-income women

Our intention in this article is to provide the reader with the theoretical framework of prenatal peer counseling. A second article describing a prenatal peer program that is functional in the province of Quebec will be presented subsequently with its outcomes and recommendations. However, before planning the implementation of such a program or even assessing its effectiveness, one must understand how peer counseling can be used as an assistive strategy and why it is perceived to be a community approach worth considering with pregnant women from poor socioeconomic backgrounds. This approach addresses most problems encountered when prenatal programs fail to meet the specific needs of these women. Principles of the therapeutic community and its derivatives are put forward to lay the theoretical foundation of prenatal peer counseling. The studies reviewed show that psychosocial variables associated with pregnancy outcome and poverty such as anxiety, social support, and self-esteem can be positively influenced through a prenatal peer counseling program. We strongly recommend that nurses working with low-income families consider prenatal peer counseling as an empowering strategy for mothers within a given community.