Laura L. McDermott, PhD, FNP, RN

Gale A. Spencer, PhD, RN

Binghamton UniversityDecker School of Nursing

THE RELATIONSHIP AMONG BARRIERS AND FACILITATORS

TO PRENATAL CARE AND BIRTH OUTCOMES IN A

RURAL COUNTY

PRESENTER DISCLOSURES

The following personal financial relationships with commercial interests relevant to this presentation existed

during the past 12 months:

“No relationships to disclose”

Laura L. McDermott, PhD, FNP, RNGale A. Spencer, PhD, RN

As of 2010, upstate New York lags behind national averages and Healthy People 2010 goals for access to first trimester PNC with only 76.1% of women accessing care in the first trimester of pregnancy.

Rural women face unique challenges.

Importance of PNC.

Previously identified PNC barriers & facilitators.

INTRODUCTION

While research has clearly identified barriers to prenatal care and they have been well identified, access to prenatal care in the 1st trimester has not greatly improved over the past decade.

Most research in the U.S. has focused on barriers to prenatal care in urban or suburban settings.

Research conducted in rural populations limited.

Few studies have been conducted on access to prenatal care within the first trimester of pregnancy among rural women.

PROBLEM STATEMENT

The purpose of this study was to examine the barriers and facilitators regarding access to prenatal care in a rural county without a hospital or birthing center within its geographical boundaries and with few health care providers who offer obstetrical care.

Prenatal care in Tioga County, New York was studied in depth using variables found in the 2008 Electronic Birth Certificate (EBC) data base and the Prenatal Risk Assessment Monitoring System (PRAMS) questionnaire which was distributed and collected from Tioga County women who gave birth in 2008.

PURPOSE OF THE STUDY

Adapted from the Behavioral Model of Utilization created Anderson and Aday (1998).

Frequently utilized framework for analyzing factors associated with patient access to health care services.

Uses a system perspective to integrate a range of personal, environmental, provider-related, and health behavior variables that either facilitate or impede a person to seek medical care, or in this case prenatal care.

CONCEPTUAL FRAMEWORK

Behavior Model of Health Service Utilization: Prenatal Care

Environment Population Characteristics Health BehaviorHealth Care

System:Tioga County

External Environment•Lack of providers

Predisposing Characteristics

Demographic:•Age of mother•Marital Status

Social Structure:•Race•Education level•Employment Status

Enabling Resources

•Wait time for appointment•Financial resources•Transportation•Insurance coverage•Medicaid Card•Work•Child Care•Time Constraints•Secrecy of pregnancy•Other•Payment source•Income Level

Community Attributes:•Rural

Need

•Perceived•Evaluated

Prenatal Risk Factors:•Smoking•Alcohol•Illicit drugs

Use of Health Services:•Trimester of pregnancy

Outcomes

Health Status

Outcomes•Infant’s birth weight in grams

Study design

This study uses a descriptive correlational design.

Two different data bases were used. 1. Secondary data from the EBC data for women who gave birth in Tioga County in 20082. Primary data collected from women who gave birth in Tioga County 2008 who completed and returned the CDC PRAM’s Questionnaire

The PRAMS questionnaire was mailed to all the women who gave birth in Tioga County in 2008. After the data collection of the PRAMS data the two data bases were combined into one for analysis.

METHODOLOGY

Sample Consisted of all the women who lived in Tioga county and

gave birth in 2008 (n = 508). Age range - 14 to 45 years (mean age = 27 years). Race: 97.3% Caucasian. Level of education

8th grade or less (2%), 9th – 12th grade (8.5%), High school graduate or GED (27%),Some college credit but no degree (22%), Associate’s degree (13.5%), Bachelor’s degree (17%), Master’s degree (10%), Doctorate degree (2%).

METHODOLOGY

Human subject protection approval was granted on April 27th, 2009.

Instruments NYS Electronic Birth Certificate Data (EBC) Center for Disease Control and Prevention (CDC) PRAMS

questionnaire Data collection PRAMS questionnaire was collected by researcher. Cover letter and pre-numbered survey was mailed to all mothers

who gave birth in Tioga county in 2008. Pre-paid self-addressed return envelope and incentive of a five

dollar gift certificate for each return survey. Data collection started on June 1st and ended August 1st, 2009. Analyzed with SPSS 16.0

METHODOLOGY

1. What is the relationship between type of health insurance coverage and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

2. What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

3. What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

4. What is the relationship between each of the enabling resources (e.g. wait time for appointment, financial resources, insurance coverage, transportation, Medicaid card, work, child care, time constraints, secrecy of pregnancy, and other reasons) and access to prenatal care in the first trimester for pregnancy in women who live in a rural county?

RESEARCH

QUESTIONS

What is the relationship between type of health insurance coverage and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

The relationship was found to be statistically significantX2 = 8.450, p = 0.015

The logistic regression for this question identified the following results: Those women who had private insurance coverage were 2.113 times more likely to access prenatal care in the first trimester of pregnancy than women who had Medicaid insurance.

Those women who had private insurance were 4.0 times more likely to access prenatal care in the first trimester of pregnancy than women who self- paid. While the Wald is not statistically significant at 0.055, it approaches statistical significance.

RESEARCH QUESTION 1

What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

The relationship was found to be statistically significant

X2 = 9.114, p = 0.028

The logistic regression for this question identified the following results: Those women who were aged 20-29 were 3.297 times more likely to access prenatal care in the first trimester of pregnancy than women who were 14-19 years of age.

RESEARCH QUESTION 2

What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?

The relationship was found to be statistically significant.

X2 = 5.113, p = 0.024

The logistic regression for this question identified the following results: Those women who were married were 1.964 times more likely to access prenatal care in the first trimester of pregnancy than women who were single.

RESEARCH QUESTION 3

What is the relationship between each of the enabling resources (e.g. wait time for appointment, financial resources, insurance coverage, transportation, Medicaid card, work, child care, time constraints, secrecy of pregnancy, and other reasons) and access to prenatal care in the first trimester for pregnancy in women who live in a rural county?

The relationship was found to be statistically significant.

X2 = 7.716; p = 0.005

The logistic regression for this question identified the following results: Those women who did want others knowing they were pregnant are 7.773 times more likely to access prenatal care in the first trimester of pregnancy than women who did not want others knowing they were pregnant.

RESEARCH QUESTION 4

RESEARCH QUESTION 4 OVERALL LOGISTIC REGRESSION ANALYSIS

Enabling Resources B Wald Sig.Odds Ratio

Appointment 0.545 0.299 0.584 0.58Financial resources 1.063 1.256 0.262 0.345Transportation 1.005 0.649 0.420 0.366Work -0.802 0.322 0.653 0.559Insurance Coverage -.0.401 0.032 0.570 2.231Medicaid Card 0.582 0.202 0.859 1.494Child Care 23.468 0.000 1 0.000Time Constraints -47.293 0.000 0.999 3.458Secrecy 1.862 1.296 0.255 0.155Other 1.992 1.706 0.191 0.136

  Constant -2.265 64.409 0.999 0.000

•Not Statistically Significant•Accept the Null Hypothesis

Women with private insurance were twice as likely to access prenatal care in the 1st trimester of pregnancy than women who had Medicaid and four times as likely as women who indicated self pay for prenatal care.

A statistically significant relationship was found between mothers identifying that they did not want anyone to know that they were pregnant and access to prenatal care in the 1st trimester.

DISCUSSION OF THE FINDINGS

Statistically significant relationship was found between Age and access to prenatal care in the 1st trimester of pregnancy.

Women aged 20-29 were more likely to seek prenatal care in the 1st trimester of pregnancy than women who were 19 or younger or 30+.

Statistically significant relationship was found between marital status and access to prenatal care in the 1st trimester of pregnancy.

Married women were more likely to enter prenatal care in the 1st trimester of pregnancy than single women.

Women who were married were more likely to have a greater number of enabling resources than women who were single.

DISCUSSION OF THE FINDINGS

Replication study should be conducted in other rural areas with different racial/ethnic background.

Rural South

Re-evaluation of facilitators and barriers in the 1st trimester of pregnancy with the expansion of Medicaid and universal health insurance.

IMPLICATIONS FOR FUTURE RESEARCH

This study was unique in several ways: 1st study to link PRAMS and EBC data for

one county. Allows the researcher to analyze barriers

and facilitators at the county level Rural women encountered more facilitators

and fewer barriers to prenatal care. Hardiness 86.7% of Tioga County women accessed

prenatal care in the 1st trimester of pregnancy.

CONCLUSION