Psychological and sociological barriers to prenatal care

Psychological and Sociological Barriers to Prenatal Care Marycatherine Augustyn, PhD Lois A. Maiman, PhD Department of Maternal and Child Health The Johns Hopkins University School of Hygiene and Public Health Baltimore, Maryland Division of Epidemiology, Statistics and Prevention Research National Institute of Child Health and Human Development National Institutes of Health Bethesda, Maryland

Abstract

This review of psychosocial characteristics of women who delay prenatal care reveals that perceptions of barriers to care need to be considered by both designers of prenatal programs and by health care professionals.

espite r e c o m m e n d a t i o n s regarding the importance of early and continued prenatal care, during the past decade the n u m b e r of infants born in the United States to w o m e n w h o either began prenatal care in the last trimester of their pregnancy or received no prenatal care has not been reduced. 1"2 In 1986, 18% of all US infants were born to w o m e n w h o delayed care until the second trimester, 4% to w o m e n w h o initiated care in the third trimester, and approximately 2% to w o m e n w h o received no prenatal c a r e ) The lack of evidence citing association b e t w e e n the removal of financial, 1"3-s organizational, and care-site 6-~s limitations and imp r o v e m e n t in access to prenatal care or birth outcomes 9 suggests other potential barriers to receiving prenatal care. 3'6'1°-16 The major focus of this article is on the sociological and psychological characteristics of p r e g n a n t w o m e n w h o delay prenatal care. Ethnic-cultural factors will be discussed in the context of their influence on prenatal and general health care utilization. " A d e q u a t e " prenatal care is generally considered to consist of initiation of care at least within the first 3 m o n t h s of pregnancy and receipt of nine medical examinations during pregnancy.1 This will be the definition applied in this review. Although a n u m b e r of d e m o g r a p h i c characteristics are associated with delayed utilization of prenatal care (including low income, 4A7-21 n o n w h i t e race, 1"3'18'22-24limited maternal 1'17'19'21'25 and paternal 2s education, age below 20 y e a r s 1'17"20'2s'26 o r above 45 y e a r s , 1'26 high p a r i t y , 1'18"21'2s'26 a n d u n m a r r i e d statusl"25"26), the associations m a y not remain significant w h e n race and income are controlled and other characteristics, such as older age and high

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parity, are covariates. In the following discussion, it is important to remember that certain demographic characteristics, not considered in the analysis, could potentially affect the study results.

P S Y C H O L O G I C A L FACTORS RELATED TO DELAYED PRENATAL CARE Factors surrounding the pregnancy itself and factors surrounding prenatal care providers each play a role in delayed prenatal care.

Attitude Toward the Pregnancy Often the attitude toward the pregnancy is more important in determining initiation of prenatal care than external factors such as lack of transportation and child care. 16 Several studies examining pregnancy "wantedness" have found that w o m e n who hold negative attitudes about being pregnant, or become pregnant unintentionally, obtain adequate prenatal care later than women who planned for or wanted their pregnancy. 3A9'27-29 Women who obtain late or no prenatal care are also more likely to have considered abortion. 3,18,29 Denial or depression associated with the pregnancy, especially among adolescents, is an important deterrent to prompt prenatal care.lS'27Adoles cents, especially primiparas, are more likely to want to conceal the pregnancy from others (mostly parents). 13"18

Attitude Toward Health Care and Providers Many w o m e n have certain negative feelings toward health care in general, and toward health care providers, and may reject the importance of prenatal care. It has been reported that w o m e n who receive inadequate prenatal care are less likely to receive other preventive care, possibly related to fear of medical procedures, t~oor past experiences, and/or lack of continuity with health care providers.°Additionally, women who are satisfied with their care and view their physicians as competent and concerned with their welfare are more likely to receive adequate care. 3'29

Belief in the Importance of Prenatal Care Belief in the importance of preventive care in general, 3° and specifically prenatal care, 29 has been shown to be related to receipt of adequate prenatal care. Women who believe medical help is not needed during pregnancy 29 and who disagree with their physicians regarding the risks 6 are less likely to receive adequate prenatal care.

Summary of the Psychological Factors Affecting Prenatal Care The preceding discussion suggests that women who do not receive adequate prenatal care are likely to conceive unintentionally, may deny or be depressed about the pregnancy, and may have considered abortion. Pregnant adolescents, especially, may want to conceal the pregnancy. Additionally, women who delay prenatal care are likely to have negative feelings about health care services and providers in general, and specifically about prenatal care. These psychological factors appear to be more common in minority w o m e n . 3"19'29

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SOCIOLOGICAL FACTORS RELATED TO DELAYED PRENATAL C A R E For the purposes of this review, sociological factors are defined as social support from friends, family members, and the father of the infant, as well as the organization of the pregnant women's social network.

Social Support and Network The interest in social support as a predictor for initiating prenatal care is based on the assumption that obstacles to obtaining prenatal care are more easily overcome if a pregnant woman is surrounded by individuals who can provide emotional and material support. 14 Findings of research studying this assumption may be conflicting because of differential definitions of social support and population differences. 14 Several of the many ways social support has been operafionalized include tangible assistance, 31 encouragement for prenatal care by family and friends, 31 positive feelings toward pregnancy expressed by siblings and friends, 32 positive feeling toward pregnancy expressed by partner and partner's family, 14 and assistance from mother. 32 When operationalized as tangible assistance, social support was found to be associated with the receipt of adequate prenatal care. However, when social support was operafionalized as encouragement for prenatal care by family and friends, it was not associated with receipt of adequate prenatal care. 31 A study of pregnant adolescents found that although positive feelings toward the pregnancy expressed by family and friends were associated with positive feelings toward the pregnancy, there was no relationship between either this emotional support or help by the adolescent's mother, and adequate prenatal care. 32 Examination of alternative definitions of social support reveals that familial support and discussions concerning pregnancy only modestly counteract barriers to obtaining adequate prenatal care. However, when operationalized as family members' happiness at the news of the pregnancy, social support was associated with obtaining adequate prenatal care. 13 Research examining the relationship between sources of social support and prenatal care found that women residing with the father of the baby (or sexual partner) were more likely to receive adequate prenatal care than women residing with other adult k i n . 33 However, conflict or problems with the father of the infant may act as a barrier to prompt initiation of prenatal care, and family and personal problems (ranging from geographic moves to imprisonment of the father of the baby) have been found to act as deterrents to prompt initiation and missed appointments. 12'34 Another study of women primarily of Mexican descent reported that support from the partner and his family was associated with initiation of prenatal care. 13 Women who were part of a local, homogenous network of mostly related individuals were found likely to delay or underutilize prenatal care. Women who utilized care tended to live farther from their relatives and closer to their friends. 13 S u m m a r y of the Effects of Social S u p p o r t o n D e l a y e d Prenatal Care Although there may be some speculation regarding the role of social support and structure in obtaining prenatal care, the lack of standardization of the conceptual operafionalizafion of social support in studies of delayed prenatal care limits the discussion of implications for specific populations. In response to pregnancy, different races and ethnic groups may provide and react to social support in different ways. It should also be noted that studies on the effects of social support on initiation of p r e n a t a l care o f t e n use s a m p l e s of single p o p u l a t i o n 22

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groups 13'14'31"32or representative by race, 6'33 rather than statistical samples of population groups. 12 Therefore, few of the studies provide empirical evidence of the role of race or ethnic differences.

CULTURAL INFLUENCES ON PRENATAL CARE During the past two decades, certain US minorities have increased more rapidly than the general population, leading to tens of thousands of foreignborn individuals residing in some Western cities. 3s Traditional beliefs, behaviors, and languages are reinforced by continued immigration. 36 Because many of these minority groups have traditionally high birth rates, prenatal care may be an ethnic woman's first contact with the health care system, but the current system (knowingly or unknowingly) has ignored their special problems and needs. The following sections discuss several potential barriers, including language, views of prenatal care, and social support.

Language For pregnant ethnic women, language differences pose similar problems in utilization of prenatal care as for any other health service utilization. A study of pregnant Mexican-American w o m e n found that those who had no or a moderate command of the English language preferred to obtain care from Latino, Spanish-speaking physicians. 37

View of Prenatal Care Members of certain ethnic groups may not be familiar or comfortable with the type of examinations and questions required during prenatal care. In the Hispanic culture, discomfort while tailing about self-breast examination and a taboo on examination by a physician when a woman is spotting or menstruating is associated with underutilization of Papanicolaou smears and mammography, 38 making it likely that similar procedures and questioning will not be accepted. Hispanic adolescents may be particularly uncomfortable talking about sexual matters. 39 For Hispanic women used to a paternalistic, traditional culture, the American physician's expectation that they actively share the process of health care is confusing, leading to a perception that the physician is weak and lacking adequate knowledge. 38 In some ethnic groups, prenatal care may be considered unnecessary. Low-income Jamaican women believe that an occasional visit to a prenatal care provider is sufficient, probably due to cultural consideration of pregnancy as a life-cycle event rather than a pathologic condition. TM It has also been reported that in some cultures, excessive vaginal bleeding is not considered a reason for great concern. 4°

Social Support The social network structure of different ethnic groups affects the utilization of prenatal care, because membership in a network of mostly related individuals can be associated with both delay or underutilization of prenatal care. 15 Mexican-American w o m e n are often part of homogenous, extended social (family) networks characterized by the exchange of mutual help 41 and, therefore, may be likely to delay prenatal care.

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Summary of the Influence of C u l t u r a l Beliefs and Behaviors on Prenatal Care Although the research on ethnic-cultural influences on delayed prenatal care utilization is limited, several conclusions may be reached: 1) for women who are not f u e n t in English, language differences probably act as a barrier to prenatal care; 2) ethnic groups may view prenatal care as intrusive or unnecessary; and 3) families and other ethnic group members may discourage (or not encourage) attending prenatal care.

C U L T U R A L I N F L U E N C E S O N H E A L T H CARE U T I L I Z A T I O N Because of limited relevant studies of the relationship between cultural beliefs and behaviors concerning pregnancy and entry into prenatal care, the following discussion explores the relationship between the utilization of general health care and these factors.

Language Nonfluency in English and cultural differences in nonverbal communication are likely to lead to preferences with obtaining care from native-languagespeaking physicians and to cause delays in initiating health care or increase likelihood of termination of care. 35'36'40"42

Folk Beliefs Many members of ethnic groups hold and respond to certain "folk" beliefs rooted in their history, which provide an alternative to formal Western health care. 42 Although it has been suggested that adherence to medical folk practices has eroded among ethnic urban-dwellers, 43 it is likely that many groups (immigrants from Haiti, Trinidad, the West Indies, Puerto Rico, Mexico, and longer-term black residents of the United States) practice some form of folk medicine. 43 In some cultures, disease and illness are considered a sign or punishment from God, an evil act of another human, or as a balancing-out of circumstances. Thus, prevention or cures are believed to require elements beyond the realm of modern US physicians. 39'44 Prior to seeking Western medical help, many ethnic group members, especially Hispanic-Americans and immigrants from the Philippines and China, 39 •42 •44 ' 45 diagnose and treat their ailments. Fear due to unfamiliarity with the techniques of modern medicine and not perceiving a place in the US health system for ethnic beliefs may also cause individuals to avoid health care. 42

Definitions of Illness Cultural differences in definitions of symptoms and illness may result in viewing symptoms of disease as normal and even essential to life. 46-5° For example, whereas white Americans most often define "hearing voices" as indicative of mental illness or hallucinations, Mexican-Americans most often interpret hearing voices as a religious experience. 4°

Priorities and Tolerance of Symptoms Living in poverty may make symptoms considered a matter of concern for upper- or middle-class white Americans (eg, chronic fatigue, fainting spells,

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persistent backache) a low priority for low-income ethnic Americans. 4°'44 Additionally, some ethnic individuals (eg, Mexican-Americans and JapaneseAmericans) may tolerate pain or inconvenience to avoid public disclosure of weakness or to fulfill familial responsibilities. 42'sl

Familial Role Many ethnic groups expect family members to be accessible to the patient to make decisions, provide emotional support, and monitor treatment. 3s'42'51 A barrier is erected when physicians, who are not open to "consultation" from the patient's family, interact with ethnic family members who are unwilling to relinquish total control of care. 35

Social N e t w o r k Structure Suchman 52 formulated a theoretical model that divided illness recognition into four transitional stages: 1) symptom experience; 2) assumption of the sick role; 3) medical care contact; and 4) recovery or rehabilitation. According to the model, an individual's decisions and behavior at each stage are influenced by the community, friendships, and family. Individuals who belong to communities or families that are characterized by ethnic exclusivity, friendship solidarity, and traditional/authoritarian family relations are less likely to practice preventive health behaviors, and they have a less "scientific view" than do members of more cosmopolitan social groups. Although at least two studies have supported this model, 52"53other research has demonstrated that high ethnic exclusivity was associated with both a high level of knowledge of health and disease 54 and a scientific medical orientation, s5 These inconsistent findings could be related to subgroup differences.

Interaction of Factors It is difficult to assess the individual barriers to health care confronting ethnic groups without mentioning the net effect. Several studies have found that ethnicity affects health behavior through an interaction with other variables, such as perceived vulnerability, previously existing chronic health problems, and poverty, s6-59 There may be more health behavior differences between people of different social classes within the same ethnic group than there are between ethnic groups. 35 In general, lower socioeconomic status individuals tend to behave in a more traditionally ethnic manner than do higher socioeconomic status individuals. 35 It appears that many members of ethnic groups may not receive adequate medical care for at least two reasons: 1) they may experience cultural barriers and 2) they are more likely than not to be poor. Cultural barriers may prevent individuals who are already more likely to suffer from a serious disease and have higher mortality rates from receiving care. 45

SUMMARY In this article, three groups of factors mitigating the utilization of prenatal and general health care have been considered: psychological, sociological, and ethnocultural. Although the factors within each group are not exclusive and often difficult to differentiate, many of them (eg, attitudes, belief in importance of care, social support) fit into behavioral models such as reasoned action, planned behavior, and the health belief model. The purpose of this article, however, is not to test the application of a particular behavioral model to prenatal care utilization but, rather, to explore the various factors that must be considered before a behavioral model can be applied.

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With this in mind, a multitude of factors that m a y play a role in determining the initiation and continuation of prenatal care have b e e n examined. Demographic variables, extremely important predictors, interact with psychological variables that interact with sociologic variables. For example, w o m e n with similar m o n e t a r y resources, but dissimilar psychological profiles, will probably have different utilization patterns. W o m e n w h o share the same ethnic heritage, but do not share the same social class, will probably behave differently. A l t h o u g h a difficult undertaking, these factors and relationships m u s t all be considered in health-promotion programs and policy interventions for p r e g n a n t w o m e n . IMPLICATIONS It is clear from this review that because multiple factors influence attendance in prenatal care, there is a n e e d for a comprehensive, multidisciplinary approach to prenatal care to attract and maintain w o m e n in prenatal care. This approach includes enhancing at least three c o m p o n e n t s of care: 1) The curriculum in professional schools (medical, nursing, social work, administration, etc) should be enhanced to include courses in social science, 49 human development, organizational theory, and administration planning. 46 2) The protocol of the medical interaction should be enhanced to include a thorough assessment of the psychosocial needs of women entering prenatal care, 12'34 referral to in-home family support services, 34 and follow-up of all missed appointments. 34 Additionally, it may be appropriate in some situations to integrate traditional healers into Western practice. 6° In the hospital after delivery, social workers may be able to contact women who had limited prenatal care to elicit barriers and educate them about the importance of prenatal care. 3 3) Community outreach and involvement that is individualized to the relevant community should also be enhanced. 12 Focus groups and individual interviews can be used to elicit the particular concerns of the community, 17 to be used for planning and implementation of programming changes. In this way, the community may feel a certain ownership of the care the women receive.48 Mass media 3's~ and school programs 51 in the community can be used to educate the importance of prenatal care. CONCLUSION In social and psychological research aimed at determining health behaviors, it has become a p p a r e n t that the perception of barriers to care is an increasingly important concept. Related to the present discussion, barriers associated with prenatal care m a y be more multifaceted, existing both in the system and the self, t h a n the b a r r i e r s a s s o c i a t e d w i t h s e e k i n g o t h e r t y p e s of h e a l t h c a r e . 3'4"7'9'12"17-20'25'26'28--30"34 Research on ways to increase utilization of prenatal care by modifying or reducing such barriers is m a n d a t o r y . Although the list of factors that we have discussed is not exhaustive, it should serve as a guide for both those w h o design programs and for health care professionals. Programs m a y be designed sensitively e n o u g h to encourage w o m e n to seek care, but if these w o m e n are not m a d e comfortable in the health care setting, they are at risk of d r o p p i n g out.

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