Prenatal care among Puerto Ricans on the United States mainland

Social Science & Medicine 51 (2000) 1723±1739

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Prenatal care among Puerto Ricans on the United States mainland R.S. Oropesa*, N.S. Landale, M. Inkley, B.K. Gorman Department of Sociology & Population Research Institute, The Pennsylvania State University, 601 Oswald Tower, University Park, PA 16803, USA

Abstract Recent public health initiatives in the USA identify the improvement of maternal and infant health outcomes among ethnic minorities as a national priority. Prenatal care is emphasized in these initiatives as a crucial intervention for reducing the risks of adverse outcomes. We investigate the barriers to prenatal care and the adequacy of prenatal care among mainland Puerto Ricans using data from a follow-back survey of a representative sample of mothers. The results show that barriers to prenatal care and the adequacy of prenatal care cannot be reduced solely to ®nancial problems or problems associated with migration. Rather, attention to the social and the psychological circumstances surrounding the pregnancy (e.g. pregnancy wantedness) is required. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Maternal and child health; Prenatal care; Ethnic minorities; Cultural circumstances; United States

Maternal and infant health care issues continue to occupy a prominent place on the public health agenda in the USA, despite substantial improvements over the last several decades in some traditional indicators of infant health. This apparent contradiction re¯ects a variety of factors, one of which is continuing unease over ethnic di€erentials in maternal and infant health.

* Corresponding author. Tel.: +1-814-865-1577; fax: +1814-863-7216. E-mail address: [email protected] (R.S. Oropesa). 1 The baseline infant mortality rate and rate of low birth weight for Puerto Rican infants stood at 12.9 (10.1 for the US population in 1984) and 9.0 (6.9 for the US population in 1990), respectively, for the development of the Healthy People 2000 objectives. By the mid-1990s, the infant mortality rate for Puerto Ricans hovered near 10 and the percent of low birth weight infants approached 9.5 (National Center for Health Statistics, 1997).

Some ethnic groups have relatively greater risks than the general population of negative health outcomes, such as low birth weight and infant mortality. This is the case for Puerto Ricans Ð a group that is singled out for special attention in the national health promotion objectives for the year 2000 by the US Department of Health and Human Services (National Center for Health Statistics, 1997)1. E€orts to improve infant health focus largely on the prenatal care component of the health care delivery system. The objective of prenatal care is to reduce the risks of adverse pregnancy outcomes. Extensive contact with prenatal care providers also can promote a healthy family environment during the ®rst years of life (US Department of Health and Human Services, 1989). Although some investigators take a less sanguine view of its impact (Albrecht & Miller, 1996; Gortmaker & Wise, 1997), various expert panels concur that ``prenatal care provides a foundation for

0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 0 1 - 5

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improving the health of the pregnant woman, infant, and family. . . the prenatal care system is a cornerstone of health care delivery in our society'' (US Department of Health and Human Services, 1989, p.1; Institute of Medicine, 1988; National Center for Health Statistics, 1997). Attention to Latinas is a high priority because of their relatively low rates of prenatal care utilization. At the same time, there is considerable variation in the receipt of medical care across the di€erent groups that are subsumed under the generic ``Latina'' label. Half (52%) of mainland Puerto Rican women have ``adequate'' prenatal care utilization. This is slightly higher than the ®gure for Mexican±American women (46%), but substantially lower than the ®gure for Cuban± American women (77%). Over three-fourths (77%) of white women receive adequate prenatal care (Landale, Oropesa & Gorman, 1999; see also Ventura, 1994). Using the Puerto Rican Maternal and Infant Health Survey, we examine prenatal care utilization among mainland Puerto Ricans. Both descriptive and analytic objectives are pursued. The descriptive objectives are to identify the major barriers to prenatal care and to determine the prevalence of inadequate prenatal care utilization. The analytic objective is to demonstrate the extent to which barriers to care and prenatal care utilization emanate from the complex set of circumstances that surround pregnancies. Special attention is paid to migration, capital accumulation, lifestyles, medical risks and pregnancy wantedness.

endowments of human and ®nancial capital. Moreover, migration allegedly uproots individuals from familiar cultural settings, communities and social networks. This loss of moorings imposes psychological and social tolls. Post-migration stress allegedly fosters marginalization from social institutions and upsets familial relationships (Zavala-Martinez, 1994, p.35)2. Thus, a guiding hypothesis is that migrants are more likely than non-migrants to face barriers to prenatal care. As a result, migrants should be less likely to obtain adequate prenatal care. Some empirical evidence is consistent with this hypothesis. Latinas born outside the United States are less likely than the native born to have adequate prenatal care utilization (Albrecht & Miller, 1996) and to start prenatal care in the ®rst trimester (Ventura & Ta€el, 1985). However, the evidence for Puerto Ricans is less conclusive. On the one hand, some scholars argue that Puerto Rican migrants tend to underutilize various preventive services such as prenatal care (Zavala-Martinez, 1994, p.35). Lederman & Sierra (1994) show that Puerto Rico-born mothers in New York City are slightly less likely than US-born Puerto Ricans to receive early prenatal care. On the other hand, some studies based on national vital registration data show that Puerto Rico-born mothers are slightly more likely than their US-born counterparts to receive adequate prenatal care and prenatal care in the ®rst trimester (Landale et al., 1999; Engel, Alexander, & Leland, 1995; see also Ventura & Ta€el, 1985). Three forms of capital

Theoretical and empirical background Scholars interested in health-related issues increasingly emphasize the centrality of the migration experience for Latinas (Vega & Amaro, 1994, p.59). Latinas face challenges that are created by the relationship between migration and the resources that are needed to perform certain health-related behaviors. Latin American immigrants are handicapped by limited English pro®ciency at the time of entry and relatively small 2 This viewpoint is consistent with what might be termed the classical perspective in immigration studies. The classical perspective portrayed migration as a disruptive experience characterized by isolation and lack of integration into social networks in the destination. More recent perspectives highlight the centrality of social networks in the migration process. 3 Medicaid is not the only government program with a potential impact on prenatal care. The Women, Infants and Children (WIC) program is designed to provide nutritional information and medical referrals to low-income pregnant women and mothers of young children.

Migration status is potentially important because it a€ects a wide range of structural risk factors for the underutilization of prenatal care Ð resources in the form of ®nancial, human and social capital. Financial capital Financial capital refers to monetary resources that can be mobilized to purchase health care and to absorb the ancillary costs of care, including childcare and transportation. Adequacy of prenatal care utilization should be directly related to access to ®nancial capital if middle/upper income women are less likely than low-income women to face ®nancial barriers to prenatal care (Bedics, 1994; Brown, 1989; Guendelman & Witt, 1992; Harvey & Faber, 1993; Kalmuss & Fennelly, 1990; Lee & Grubbs, 1995; Lia-Hoagberg et al., 1990; McDonald & Coburn, 1988; Schae€er & LiaHoagberg, 1994). A case can be made for de-emphasizing ®nancial constraints, in part because governmental programs such as Medicaid provide indigents with access to medical care3. However, Medicaid `` . . . does not ensure the scope of services, content of care, and organization

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of services necessary to address the needs of women with low incomes'' (Guyer, 1990, p.2265). Medicaid recipients must deal with a humbling bureaucracy, a daunting application procedure and a limited supply of physicians who will accept them as patients. Thus, women with Medicaid coverage typically enter into prenatal care later and utilize prenatal care less frequently than women who have alternative forms of coverage (Joyce & Grossman, 1990; Kinsman & Slap, 1992; McDonald & Coburn, 1988; Nassirpour & Jensen, 1992; St. Clair, Vincent, Alexander, Connell & Niebyl, 1990; Zambrana, Dunkel-Schetter & Scrimshaw, 1991; but see Parchment, Weiss & Passanante, 1996). This set of ®ndings is particularly relevant to Puerto Ricans. In keeping with their socioeconomic pro®le, Puerto Ricans are more likely than any other Latino group to receive health care from public institutions and to receive Medicaid (Schur, Berenstein & Berk, 1987). Lazarus and Philipson (1990) argue that Puerto Ricans are reticent to go to public clinics because of long waits, little face-to-face interaction with doctors, the lack of continuity of care and communication diculties arising from language di€erences (see also Guendelman & Witt, 1992). Such circumstances make it dicult to establish trust between the provider and a patient who may be depersonalized into a set of symptoms and conditions. In turn, this may make it dicult to follow cultural scripts that emphasize mutual respect and empathy in interpersonal relations (Quesada, 1976; Zavala-Martinez, 1994). In short, the health care system can create barriers to frequent utilization4. Human capital Prenatal care is also linked to human capital Ð skills and expertise acquired through experience. Schools increase endowments of human capital by exposing students to health-related programs and courses. Education also facilitates prenatal care utilization by increasing the capacity to process information 4

This viewpoint is consistent with that of many prenatal care professionals who suggest that ``uncoordinated, unfriendly systems often produce unhappy providers as well as unhappy patients'' (Curry, 1989, p.93). Providers also feel that many barriers to e€ective prenatal care involve `` . . .negative personal characteristics. The adjectives used to describe these characteristics included insensitive, judgmental, sexist, rude, hostile, and patronizing. Providers' inability to e€ectively teach, counsel, and communicate was identi®ed. . .Other barriers included failure to remain current, discrimination against certain client groups. . .and failure to maintain con®dentiality'' (Curry, 1989, p.93). Nevertheless, some studies suggest that the majority of Latinas do not perceive a great deal of discrimination on the part of providers (QueiroTajalli, 1989)

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through mastery of both the spoken and written word. In addition, individuals accumulate experience outside of educational institutions and learn about proper behaviors during pregnancy as they grow older. This is why prenatal care utilization is associated with both education and age among the general population (Casper & Hogan, 1990; McDonald & Coburn, 1988) and Latinas (Albrecht & Miller, 1996; excepting Zambrana et al., 1991). Social capital Individuals di€er in their access to social capital in the form of resources from social relationships (Coleman, 1990). Social relationships characterized by mutual obligations and trust serve as resources that can assist the individual. They are the conduits along which support and information ¯ow. As such, social relationships facilitate action. For example, marriage typically re¯ects more extensive and more stable obligations between partners than alternative types of intimate relationships. The obligations that form the basis of the marital bond are multi-faceted and include monetary and non-monetary support. This could explain why married women are more likely than unmarried women to secure adequate prenatal care (Albrecht & Miller, 1996; Roberts & Allen-Meares, 1995; Zambrana et al., 1991). Earlier we suggested that ®nancial constraints impinge on the ability of mothers to obtain childcare and transportation to prenatal care appointments. But ®nancial constraints can be overcome by social capital. Spouses, friends and relatives are trusted ``low cost'' alternative providers of services who lower barriers (Kinsman & Slap, 1992; Lee & Grubbs, 1995; LiaHoagburg et al., 1990; Young, McMahon, Bowman & Thompson, 1989). They urge prospective mothers to seek care, accompany them to appointments and express concern about the baby's and mother's health (Scha€er & Lia-Hoagberg, 1994). Several other studies do not conclude that social support promotes prenatal care (Casper & Hogan, 1990; Zambrana et al., 1991). Indeed, family and friends may inhibit care among Latinas (Albrecht & Miller, 1996, p.55). Latino families and friends form an ``informal'' health care network that is a repository of expertise about pregnancy (Quesada, 1976). This network reinforces norms and encourages lifestyles that are consistent with the emphases of prenatal care, such as the importance of a healthy diet and rest. Albrecht and Miller (1996, p.56) note that ``close family relationships may contribute to better prenatal care even when this does not occur through the formal health care system. . .underutilizers are more embedded in networks of family and kin and this, in turn, can lead to decreased reliance on professional providers.''

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Lifestyles and pregnancy wantedness The foregoing suggests that social and economic structures a€ect utilization by erecting a diverse set of barriers that emanate from the circumstances of daily living. These circumstances are also re¯ected in lifestyles. Speci®cally, women who experience stressful life events or consume potentially addictive substances may be less willing to seek out prenatal care. Stressful life events and the consumption of addictive substances can shift priorities, absorb time and energy and interrupt everyday routines. Addictive substances can also cloud judgement about the desirability of receiving prenatal care, especially if providers are likely to advise users to stop and schedule more frequent follow-up visits to closely monitor the pregnancy. Hence, some research shows that substance use is associated with delayed initiation of prenatal care, but more frequent visits once care is started (Zambrana et al., 1991). Other research indicates that the association between substance abuse and prenatal care is spurious Ð substance abuse is not signi®cant once the presence of the infant's father in the home is controlled (Abma & Mott, 1991). Psychological dispositions related to the pregnancy itself raise other barriers. Women with unwanted pregnancies underutilize prenatal care, especially during the early period when the desire to hide a pregnancy is at its peak and abortion is under consideration (Bedics, 1994; Harvey & Faber, 1993; Joyce & Grossman, 1990; Weller, Eberstein & Bailey, 1987; Young et al., 1990). Prenatal care utilization is also linked to a lack of awareness of the pregnancy and ``denial'' brought about by delays in the onset of physical symptoms (Harvey & Faber, 1993; Kalmuss & Fennelly, 1990; Kinsman & Slap, 1992; Lee & Grubbs, 1995).

as a generic group. This is an important limitation given that Puerto Ricans are ``targeted'' in national health initiatives. Second, prior studies tend to rely on local surveys administered to non-probability samples or on vital registration data. Non-probability samples are not necessarily representative. Vital registration data provide comprehensive coverage of the target population, but lack a rich array of covariates (e.g. ®nancial resources, social ties and psychological dispositions) that can shed light on prenatal care. Thus, few studies provide a comprehensive portrait of prenatal care utilization among a representative sample of Puerto Ricans. Using a health survey administered to a probability sample of Puerto Rican women in the eastern United States, our investigation overcomes these shortcomings. We pursue both descriptive and analytic objectives. The descriptive objectives are to document the barriers to prenatal care and the adequacy of prenatal care utilization. Some studies suggest that ®nancial barriers are most pervasive among low-income populations. Others suggest that non-®nancial barriers predominate, such as those that re¯ect the quality of service delivery and the complex psychology of ``wanting'' a child. In addition to indicating the magnitude of ®nancial and non-®nancial barriers, we describe the linkages between barriers and adequacy of care. The analytic objective is to investigate the linkages between prenatal care utilization, the number of selfreported barriers and a comprehensive set of covariates. Among the covariates just reviewed, migration is of special interest because it has implications for the locations of individuals within larger economic and social structures that determine the ®nancial and social capital at their disposal. Yet, the consequences of the various forms of capital, lifestyle behaviors and psychological characteristics are of interest in their own right.

Research issues

Data and methods

Many previous studies of the relationships between socioeconomic characteristics, various barriers to care and the adequacy of prenatal care have important limitations. First, Latinas are typically ignored or treated

This study is based on the Puerto Rican Maternal and Infant Health Survey (PRMIHS). The PRMIHS data consist of 2631 personal interviews with a strati®ed sample of Puerto Rican mothers of infants identi®ed from 1994±95 birth and death certi®cates. Sample strata include geographic location, infant health outcome and birth month. Geographic strata consist of the Commonwealth of Puerto Rico and six administrative areas that account for a large majority (72%) of all births to mainland Puerto Ricans Ð Connecticut, Florida, Massachusetts, New Jersey, New York City, and Pennsylvania. Health outcome strata comprise infants who are normal birth weight (<2500 g), low birth weight (<2500 g), and died during the ®rst year

Ironically, social relationships and family obligations may provide an alternative to formal health care5.

5 One should not conclude from this that Latinas are necessarily superstitious and rely on folk medicine. Lazarus and Philipson (1990) suggest that explanations from medical providers have more credibility than folk explanations from family and friends. Similarly, Queiro-Tajalli (1989) argues that Latinas accept the medical model and do not utilize home remedies and folk healers. Only about one-third of her respondents would consult with relatives before seeking outside medical help with pregnancy.

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of life. Normal and low birth weight infants were identi®ed from birth certi®cates and deceased infants were identi®ed from death certi®cates. Because we are interested in prenatal care in the United States, we focus on the 1255 Puerto Rican mothers who were sampled from mainland birth certi®cates and subsequently interviewed. The response rate for the mainland birth sample is 76%. The weighted birth sample is a representative sample of births to Puerto Rican women in the study areas during 1994± 956. Cases with missing values are not excluded from the analysis to avoid erroneous inferences from the rejection of cases that are not missing completely-at-random. Instead, Bayesian procedures for the multiple imputation of missing data were employed (Schafer, 1997). Five imputations were made to generate values for missing data. Each of the ®ve datasets was then analyzed with SUDAAN (release 7.5.1) to generate the correct parameter estimates and standard errors, given the complex sampling design. The results were then combined to yield estimates, standard errors and pvalues that re¯ect uncertainty about missing data (Rubin, 1987; Schafer, 1997).

Prenatal care: barriers and utilization This analysis focuses on both the barriers to prenatal care and the adequacy of prenatal care. Barriers are circumstances that make it dicult to obtain timely and frequent care. Any attempt to identify the salient barriers to prenatal care must compare the circumstances of both those who receive adequate prenatal care and those who receive inadequate care. All respondents were ®rst asked whether they received prenatal care as early and as frequently as they wanted. Those who lacked early or frequent care were then asked if this was due to problems with: (1) childcare; (2) transportation to the clinic or doctor's oce; (3) ®nding a doctor or nurse to take the respondent as a patient; (4) getting appointments; (5) feeling uncomfortable in doctor's oces, clinics or hospitals; (6) getting enough money or insurance to pay for visits; (7) ®nding out where to go for prenatal care; (8) unaware of pregnancy; (9) concern about other people ®nding out 6 Mother's ethnicity was the main criterion to determine eligibility for the birth sample. Puerto Rican infants were de®ned as births to mothers whose ethnicity was designated as Puerto Rican on the birth certi®cate. Each interview was conducted in either Spanish or English, depending on the preference of the respondent. Lastly, the representativeness of the birth sample ensures that it will include infants who subsequently died before their ®rst birthday.

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about the pregnancy; (10) unsure of wanting to carry pregnancy to term. Respondents who received early and frequent prenatal care answered a comparable series of questions about whether or not various ``circumstances made it dicult to get prenatal care''. The list of circumstances for this group was identical to that described above, except the ``awareness'' item was excluded. Lack of awareness is unlikely to be a barrier for those who receive prenatal care as early and as frequently as they want. The descriptive analysis will concentrate on both the individual barriers and a summary measure that identi®es those who did not mention any barriers, those who mentioned a single barrier and those who mentioned multiple barriers. The multivariate analysis will focus on the ``barriers index'' for the sake of brevity. The second measure is the Adequacy of Prenatal Care Utilization Index (Kotelchuck, 1994a). This index is constructed with information from the birth certi®cate and standards developed by the American College of Obstetricians and Gynaecologists (ACOG). Speci®cally, the index describes the overall adequacy of prenatal care as a function of the month in the pregnancy when care began and a ratio of the observed number of prenatal care visits to the ACOG recommended number of visits given gestational age (Kotelchuck, 1994a). ``Adequate plus'' utilization is de®ned as care that began in months 1±4 of the pregnancy with the number of observed visits exceeding the number of expected visits by at least 10%. ``Adequate'' care is initiated in months 1±4 with the observed number of visits between 80 and 109% of the number recommended. ``Intermediate'' care is initiated in months 1±4 with between 50 and 79% of the recommended visits. ``Inadequate'' utilization involves the initiation of care after the fourth month of the pregnancy (regardless of the number of visits to a provider) or less than 50% of the recommended visits to a provider (regardless of the month of initiation). It should be noted that the ``inadequate care'' designation includes women who did not receive any prenatal care, primarily because too few respondents (2.2%) are in the ``no care'' category to analyze separately. This is consistent with Kotelchuck's approach (Kotelchuck, 1994a,b). These category labels are deceptive from a measurement standpoint. Designations ranging from ``inadequate'' to ``adequate+'' imply that the index should be treated as an ordered categorical variable. This is not appropriate because the prenatal care index does not just re¯ect the frequency of visits, it also re¯ects the timing of the initiation of prenatal care. The timing of the initiation of care may override frequency of visits for the ``inadequate'' category. Also, the ``adequate+'' category is qualitatively di€erent from the ``adequate'' category. As opposed to the

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``adequate'' category, some women in the ``adequate+'' category may have frequent visits due to higher risks of negative infant health outcomes. This suggests a di€erent sorting process for this group. Thus, the index is analyzed with statistical techniques for unordered categorical variables. Covariates Several question modules focus on the circumstances of the respondent around the time of pregnancy. Migration status Mainland-resident women who were born on the island are classi®ed as migrants (1=migrants, 0=nonmigrants). Financial capital Financial resources are measured directly with a question on household income at the time of the pregnancy. Thirteen response categories were coded to their midpoints and income is treated as a continuous variable. Additional variables include employment status at the time of pregnancy (1=employed, 0=not employed) and the method of payment for pregnancyrelated health care expenses. Respondents who relied on insurance and other forms of payment are contrasted separately with those who relied on government programs. Human capital All indicators of human capital assume that knowledge is a function of life experience. A traditional measure of human capital is formal education. Dummy variables contrast those who did not graduate from high school (the reference) with those who graduated from high school and attended college. Because life experience is also gained as women age and bear children through the life cycle, we include age at pregnancy and the number of children borne by the mother prior to the pregnancy. Language utilization is measured with questions on the language that respondents use when they are at home, when they are with friends and when they watch television (i.e. the language spoken on television programs that they watch). The respondents indicated whether English is spoken most of the time, both English and Spanish are spoken about equally, or Spanish is spoken most of the time in these various contexts. The responses to these items were summed to create a 7 These questions were answered separately from the main interview with ``paper and pencil'' and returned to the interviewer in an envelope to safeguard the privacy of the respondents.

language use index (Chronbach's alpha exceeds 0.7). High scores on the index indicate greater Spanish utilization. Social capital Social capital refers to resources from social relationships marked by trust, support, commitments and obligations. A direct indicator is the response (1=yes, 0=no) to the question: ``Was there anyone you could rely on for emotional support or advice during your pregnancy?'' Commitments and obligations are also re¯ected in marital status at the time of pregnancy: legally married to the baby's father, single and living with the baby's father (cohabiting), and single and not living with the baby's father. Mothers are an additional source of social capital. Because preliminary analyses indicate that mothers are one of the most important sources of social support, we include the travel time between the respondent's home and the home of her mother or the mother of the baby's father (whomever is closest). The ability to mobilize social capital should be a function of travel time. Lifestyle behaviors Lifestyle behaviors include the consumption of substances (such as tobacco, alcohol and drugs) that are potentially addictive and associated with adverse pregnancy outcomes. Each woman indicated whether she smoked tobacco, drank alcoholic beverages, smoked marijuana or took cocaine in the three months prior to her pregnancy7. These questions are reduced to two variables that indicate whether the respondent smoked tobacco or consumed alcohol/drugs during the reference period. Lifestyles are also re¯ected in experiences with the following stressful events during pregnancy: (1) someone very close had a bad problem with drinking or drugs; (2) husband/partner went to jail; (3) homelessness; (4) job loss; (5) a lot of bills that could not be paid; (6) involvement in a physical ®ght; and (7) hit or physically hurt by husband/partner. Those with multiple and single events are distinguished from those with no events. Pregnancy wantedness The respondents were asked to think back to the time just before they became pregnant and to indicate how they felt about becoming pregnant. Those who wanted to become pregnant in the future, those who did not want to become pregnant at any time and those who had never thought about the issue are contrasted with those who wanted to become pregnant at or before the time of conception.

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739 Table 1 Adequacy of prenatal care and barriers (N = 1255)a Percent (A) Kotelchuck Index: Adequate+ Adequate Intermediate Inadequate (B) Number of barriers: Two or more One None (C) Types of problems during pregnancy: Money Transportation Childcare Locating a provider Acceptance by provider Getting appointments Unaware of pregnancy Feel uncomfortable at doctor's oce, clinics Wanted to keep pregnancy secret Unsure about carrying pregnancy to term

19.6 36.3 25.1 18.9 21.9 26.3 51.9 7.9 8.9 4.7 3.3 3.6 5.3 9.9 11.0 12.8 20.7

a All frequencies are based on weighted data. The cell entry for each type of problem during pregnancy indicates the weighted percentage of respondents answering ``yes''.

Medical risk factors Medical risk factors include experiences with previous pregnancies and conditions during the pregnancy with the focal child that could a€ect interest in prenatal care. Previous pregnancies that resulted in pre-term births, low birth weight infants, infant deaths and miscarriages could heighten interest among both women and health care providers in closely monitoring the pregnancy. Women who experienced any of these outcomes were coded as one, zero otherwise. In addition, a dummy variable was created from information on 8 The percentage for lack of awareness is depressed by the inclusion of women in the denominator who received care as early and as frequently as they wanted. As noted above, lack of awareness is extremely unlikely to have been much of a dif®culty for this group. Lack of awareness is a major barrier among who did not receive care as early or as frequently as they wanted. Nearly half of this group (47%) indicates that they delayed the initiation of care or had an insucient number of visits because they were unaware that they were pregnant. 9 The ®gure for childcare is depressed by the inclusion of women who were childless before the birth of the focal child in the denominator (childcare cannot be a problem for women without children). However, only 6.7% of women with children prior to the birth of the focal child mentioned problems with childcare.

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the birth certi®cate to identify those who experienced any of the following risk factors during the pregnancy with the focal child: anaemia, cardiac disease, acute/ chronic lung disease, diabetes, genital herpes, hydramnios/oligohydramnios, hemoglobinpathy, chronic hypertension, pregnancy-associated hypertension, eclampsia, incompetent cervix, renal disease, Rh sensitization, uterine bleeding or other medical risk factors. Time since birth Because error in responses to retrospective questions is sensitive to both issue/event saliency and memory decay (Pearson, Ross & Dawes, 1994; Loftus, Smith, Klinger & Fiedler, 1994), the last covariate measures the number of days that elapsed between the birth of the focal child and the interview. This serves as a control variable that is excluded from the presentation of results for the sake of parsimony. Results Table 1 provides the frequency distributions for the dependent variables. Panel A shows that only 56% of mainland Puerto Rican mothers received adequate or adequate+ care. Approx. 25% received intermediate care and 19% received inadequate care. Interestingly, these percentages are similar to those for the number of barriers. Panel B shows that half of the respondents did not mention any barriers, one-quarter faced only one barrier, and one-®fth faced multiple barriers. Panel C presents frequencies for the speci®c types of barriers. Among the most frequently mentioned barriers are those that directly involve the pregnancy itself Ð indecision about whether to carry the pregnancy to term, the desire to keep the pregnancy secret and a lack of awareness of the pregnancy8. These are followed by problems that are often associated with inadequate ®nances and access to the medical system. Less than 10% of the respondents mentioned ®nancial, transportation and childcare problems9. Although 11% of the respondents said they felt uncomfortable in doctors' oces, relatively few respondents reported logistical problems with service providers (i.e. locating a provider, making appointments, getting accepted by a provider). Table 2 cross-tabulates the prenatal care index by barriers. As expected, the association between adequacy and the number of barriers is signi®cant in Panel A. Women with barriers were much more likely than women without barriers to experience inadequate care. One-tenth of women with no barriers received ``inadequate'' levels of care. This contrasts sharply with the nearly one-quarter and one-third of women reporting single and multiple barriers, respectively, who responded similarly. Moreover, the composition

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of the inadequate category is weighted heavily towards those who experienced at least one of the barriers examined herein. Sixty-nine percent of those with inadequate care mentioned one or more barriers. About 42% of those with adequate care and 46% of those with adequate+ care mentioned any barriers (not shown). The remaining panels suggest that a diverse set of barriers is responsible for inadequate prenatal care utilization. Indeed, prenatal care is associated with every barrier except appointments (Panel G). For example, the second most frequently mentioned problem is the desire to keep the pregnancy secret (Panel J). Women who wanted to hide their pregnancy were more likely

to receive inadequate care than those who did not want to hide their pregnancy. Approx. 27% of those who wanted to keep their pregnancy secret and 18% of those who did not want to keep their pregnancy secret received inadequate care. Moreover, secrecy primarily di€erentiates those who receive inadequate and intermediate levels of care. The percentages of each group who secured adequate and adequate+ care are similar. Noteworthy di€erences in ``inadequate'' levels of care are also evident for the other barriers, but we will limit our discussion to those barriers that are mentioned most frequently. Some of the largest di€erences in prenatal care are shown for those

Table 2 Adequacy of prenatal care by barriersa Adequacy of prenatal care Barriers (A) Number of barriers: w 2=58.2, p < 0.001 Two or more One None (B) Money: w 2=27.4, p < 0.001 Yes No (C) Transportation: w 2=15.4, p < 0.01 Yes No (D) Childcare: w 2= 14.4, p < 0.01 Yes No (E) Locating a provider: w 2= 12.4, p < 0.01 Yes No (F) Acceptance by provider: w 2= 12.6, p < 0.01 Yes No (G) Getting appointments: w 2= 2.7, p < n.s. Yes No (H) Unaware pregnant w 2= 20.3, p < 0.001 Yes (unaware) No (aware) (I) Uncomfortable at doctor's oce: w 2= 8.9, p < 0.05 Yes No (J) Wanted to keep pregnancy secret: w 2= 9.8, p < 0.05 Yes No (K) Unsure about carrying to term: w 2= 17.8, p < 0.01 Yes No a

Inadequate (%)

Intermediate (%)

Adequate (%)

Adequate+ (%)

Total (%)

30.4 24.3 11.3

19.0 26.0 27.4

31.2 31.5 40.9

19.3 18.2 20.4

100.0 100.0 100.0

36.9 17.4

13.1 26.2

27.4 37.1

22.5 19.4

100.0 100.0

28.3 18.0

31.8 24.5

30.5 36.9

9.4 20.6

100.0 100.0

37.5 18.0

19.3 25.5

30.5 36.6

12.7 19.9

100.0 100.0

38.4 18.2

21.7 25.3

32.9 36.4

7.0 20.0

100.0 100.0

37.4 18.2

10.8 25.7

33.2 36.4

18.6 19.6

100.0 100.0

22.5 18.7

31.3 24.8

29.6 36.7

16.6 19.8

100.0 100.0

33.3 17.3

24.4 25.3

29.1 37.1

13.1 20.3

100.0 100.0

28.1 17.8

24.0 25.3

30.4 37.0

17.5 19.9

100.0 100.0

27.2 17.7

19.4 26.0

33.0 36.8

20.4 19.5

100.0 100.0

22.0 18.1

18.8 26.8

32.1 37.4

27.0 17.7

100.0 100.0

Row totals may deviate from 100.0 due to rounding error.

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

1731

Table 3 Odds ratios from multinomial logistic regressions: number of barriersa Model 1

Migration status Migrant Financial capital Income Employed Method of payment: Insurance Other Government (ref.) Human capital Education: College High School Less than High School (ref.) Age of Mother Number of children Language Social capital Union status: Legally married Cohabiting Single (not cohabiting Ð ref.) Proximity of mother/ mother inlaw: More than 0.5 hour 0.5 hour or less In same home (ref.) Emotional Support/Advice Lifestyle: Alcohol and/or drugs Smoked Stressful events: Two or more One None (ref.) Pregnancy wantedness Wanted baby in future Did not want baby Never thought about it Wanted pregnancy (ref.) Medical risk factors Medical complications, focal pregnancy Negative outcomes, previous pregnancies a

Model 2

Model 3

Single vs. none

Multiple vs. none

Single vs. none

Multiple vs. none

Single vs. none

Multiple vs. none

0.87

0.74

0.82

0.88

0.99d 0.59d

0.98d 0.61c

1.00 0.75

1.00 0.91

0.57c 0.85 1.00

0.37e 0.89 1.00

1.04 0.97 1.00

0.65 0.99 1.00

0.68 0.83 1.00 0.99 1.31e 1.02

0.60c 0.64b 1.00 0.96b 1.17c 0.93

1.22 1.04 1.00 0.97 1.37d 1.03

1.15 0.86 1.00 0.96 1.15 0.96

1.32e

1.08

0.48d 0.67 1.00

0.23e 0.55c 1.00

0.61 0.64b 1.00

0.39c 0.59b 1.00

0.53d 0.62b 1.00

0.28e 0.56c 1.00

1.20 0.84 1.00 0.74

0.72 0.62b 1.00 0.48d

1.47 0.95 1.00 0.95

1.11 0.82 1.00 0.55c

0.91

0.54c

0.98 1.29

0.74 1.41

1.09 0.97

0.66 1.06

1.78c 0.89 1.00

2.55e 1.13 1.00

1.53b 0.85 1.00

2.12d 1.06 1.00

1.54b 0.88 1.00

2.05d 1.07 1.00

1.56b 2.38c 2.76d 1.00

2.24d 6.33e 2.40d 1.00

1.36 1.67 2.15c 1.00

1.75c 5.18e 1.63 1.00

1.46 1.56 2.15c 1.00

1.91c 4.61e 1.78c 1.00

1.05

1.24

1.06

1.27

1.20

1.50c

1.09

1.70c

1.10

1.65c

All analyses are performed with SUDAAN after multiple imputation. Model 1 is the bivariate model, Model 2 includes all covariates, and Model 3 is limited to the ``best predictors''. b p < 0.10; cp < 0.05; dp < 0.01; ep < 0.001.

1732

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

who faced knowledge and psychological barriers. One-third of those who were unaware that they were pregnant received inadequate care, a ®gure that is double that of those who were aware of their pregnancy. This latter group was more likely to receive adequate and adequate+ levels of care. Those who felt uncomfortable in doctor's oces also were more likely than those who did not feel uncomfortable in doctor's oces to receive inadequate care. Among the largest di€erences in the table are those generated by the presence of ®nancial barriers. Nearly 37% of those who mentioned money problems received inadequate care, in comparison to 17% of those who did not mention ®nancial problems. This de®cit is re¯ected in the relative percentages for intermediate care and adequate care. Similar conclusions hold for those with transportation problems. The last panel reveals an interesting pattern for consideration of abortion. The di€erence between those who were unsure about carrying their pregnancy to term and those who were not unsure about carrying their pregnancy is substantial for the adequate+ category (27% vs. 18%). Women who were unsure about carrying their pregnancy to term may have had greater contact with medical service providers to gather full information to make an informed decision. Moreover, prenatal care is designed to diagnose conditions that may signal an unhealthy fetus or a dicult pregnancy. The information provided by prenatal care providers could raise questions about the desirability of carrying the pregnancy to term, and require more frequent monitoring of the pregnancy once the decision to have the baby is made. Tables 3 presents odds ratios generated from a series of multinomial logistic regression models for the number of barriers: Model 1 shows bivariate associations, Model 2 shows associations from a regression that includes all covariates, and Model 3 shows associations from a regression that is restricted to all variables that 10 The estimation of Model 3 involved an intermediate step that is not shown here. All variables with at least one signi®cant coecient ( p < 0.10) in Model 1 or 2 were included in a separate regression. Variables which failed to achieve signi®cance were then excluded and Model 3 was re-estimated. 11 Additional analyses explored issues surrounding the nonsigni®cant coecients for income in the full model because employment contributes income and both employment and income facilitate the purchase of insurance. The results do not suggest that the failure to observe signi®cant coecients for income stems from the inclusion of either employment or method of payment in the same model.

are signi®cant in either Model 1 or 210. We focus the discussion on Models 1 and 2. Model 2 is emphasized over Model 3 because the inclusion of all theoreticallyrelevant variables a€ords a more rigorous evaluation of the hypotheses. Nevertheless, inferences about the nature of associations from Models 2 and 3 are very similar. One variable that stands out in the various models is pregnancy wantedness. The odds of mentioning multiple barriers are much higher for women who did not want a baby or wanted a baby in the future than the odds for women who wanted the pregnancy at the time it occurred. In Model 2, the odds of mentioning multiple barriers for women who did not want to be pregnant are over ®ve times the odds for women who wanted to be pregnant. The odds for women who wanted to be pregnant in the future are nearly twice the odds generated by the reference group. The multivariate results are less impressive for other variables, especially for indicators of migration status, ®nancial capital and human capital. Speci®cally, migration status is not signi®cant in any model. And while the bivariate odds ratios in Model 1 suggest that the likelihood of facing single or multiple barriers increases with prior childbearing and decreases with income, employment, the utilization of private insurance, education and age, the number of children borne prior to the focal child is the only variable from this list that generates a signi®cant multivariate parameter estimate11. Two indicators of social capital are generally consistent with expectations in Models 1 and 2. Married and cohabiting women are less likely than single mothers to mention barriers. The odds of mentioning multiple barriers among those who were legally married and cohabiting are 0.4 and 0.6 the odds generated by those who were single in Model 2. Access to someone who can provide emotional support and advice also reduces the likelihood of mentioning multiple barriers. Barriers are also associated with lifestyles and medical risks. Although smoking and alcohol/drug use are not signi®cant, an odds ratio of 2.1 in Model 2 indicates that respondents who experienced multiple stressful events were more likely than those who did not experience any stressful events to mention barriers to prenatal care. As for medical risks, women with negative outcomes in previous pregnancies are more likely than women without previous negative outcomes to mention barriers to care. Medical complications and barriers are unrelated. The implications of the number of barriers and the other variables of interest for prenatal care can be seen in Table 4. As expected, all models show that those who mentioned multiple and single barriers are less likely than those who did not mention barriers to

Barriers Multiple Single None (ref.) Migration status Migrant Financial resources Income Employed Method of payment: Insurance Other Government (ref.) Human capital Education: College High School Less than High School (ref.) Age of mother Number of children Language Social capital Union status: Legally married Cohabiting Single (not cohabiting Ð ref.) Proximity of mother: More than 0.5 hour 0.5 hour or less In same home (ref.) Emotional support/advice 2.19d 2.12d 1.0 1.02 0.75d 0.94 1.46 0.89 1.0 1.09 1.21 1.0 2.18d

1.05 1.79c 1.0

0.98 0.79c 0.96

1.60 1.19 1.0

0.65 0.83 1.0 1.46

0.85 1.54 1.0

1.56 0.37 1.0

0.84 1.04 1.0 1.12

0.78 0.86 1.0 1.15

1.51 1.34 1.0

1.20 1.43 1.0

2.83e 0.54 1.0

1.67b 0.37 1.0

0.98 1.52

1.99c 1.52 1.0

2.74d 2.25 1.0

1.02c 2.78e

1.00 1.64b

1.14

0.99 0.90 0.94

1.01 2.22c

0.85

1.06

1.03 0.81b 1.03

1.53

0.28e 0.36e 1.0

0.26e 0.44d 1.0

0.31e 0.51c 1.0

1.35 1.39 1.0 1.71b

0.61 0.76 1.0

1.02 0.83 0.98

1.06 1.48 1.0

1.74 0.44 1.0

0.99 1.85c

0.96

0.38e 0.45d 1.0

0.45b 0.77 1.0 0.77

0.90 1.39 1.0

1.05b 0.81 0.98

0.52 1.00 1.0

2.42b 2.88 1.0

0.99 2.00b

1.59

0.49c 0.56 1.0

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate 0.35d 0.41b 1.0

Model 2

Model 1

Table 4 Odds ratios from multinomial logistic regressions: adequacy of prenatal carea

1.28

1.44

0.30e 0.48c 1.0

1.98c

0.47c 0.50b 1.0

1.83c 0.92 (continued on next page)

2.42e

0.37e 0.44d 1.0

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate

Model 3

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739 1733

1.69b 0.66 0.84 1.63 1.0 0.66 0.36c 0.40c 1.0 1.06 0.88

0.91 1.68 1.0

0.74 0.52 0.72 1.0

0.84

0.51d 1.38

0.64b

0.86

0.71 0.89 0.97 1.0

0.42d 0.16d 0.23e 1.0 1.18

1.08 1.75b 1.0

1.46 0.81

0.61 0.79 1.0

1.17 0.39d

1.05

1.14

0.65 0.50 0.58 1.0

1.08 1.87c 1.0

1.47 0.82

1.85c

1.19

0.47c 0.21d 0.33d 1.0

0.86 0.98 1.0

1.31 0.43c

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate

1.42 0.66

Model 2

Model 1

0.58c

0.79 0.76 0.90 1.0

1.18 1.78b 1.0

0.80

1.00

0.71 0.52 0.53b 1.0

1.10 1.77b 1.0

0.85

1.57

0.47d 0.21d 0.29d 1.0

0.87 0.82 1.0

0.43c

Intermediate Adequate Adequate+ vs. vs. vs. inadequate inadequate inadequate

Model 3

a All analyses are performed with SUDAAN after multiple imputation. Model 1 is the bivariate model, Model 2 includes all covariates, and Model 3 is limited to the ``best predictors''. b p < 0.10; cp < 0.05; dp < 0.01; ep < 0.001.

Lifestyle Alcohol and/or drugs Smoked Stressful events: Two or more One None (ref.) Pregnancy wantedness Wanted baby in future Did not want baby Never thought about it Wanted pregnancy (ref.) Medical risk factors Medical complications, focal pregnancy Negative outcomes, previous pregnancies

Table 4 (continued )

1734 R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

receive adequate care12. Moreover, some results for other covariates such as pregnancy wantedness mirror those in the previous table. Model 1 shows that those who did not want to be pregnant were substantially less likely to receive adequate and adequate+ care. In Model 2, the parameter estimate generated by this group for the inadequate±adequate contrast is not signi®cant, but the odds of receiving adequate+ care for those who did not want to be pregnant are one-®fth the odds ( p < 0.01) of those who wanted their pregnancy. Odds ratios signi®cantly below unity for this contrast are also evident among those who wanted a baby in the future or had never thought about the issue. We will return (below) to the non-signi®cant parameter estimates for di€erent categories of pregnancy wantedness for the inadequate±adequate contrast. Adequacy of prenatal care is not associated with migration status or income in the multivariate model. At the same time, the likelihood of receiving adequate care increases with employment. In Model 2, the odds ratio generated by employment is 1.85 for the inadequate±adequate contrast and 2.0 ( p < 0.07) for the inadequate±adequate+ contrast. The signi®cant odds ratios in Model 1 and a pattern of parameter estimates that culminates in a borderline signi®cant odds ratio of 2.4 ( p < 0.08) in Model 2 for private insurance is also noteworthy. Nevertheless, con®dence in this ®nding must be tempered by the failure of payment method to enter Model 3. Indicators of human capital and social capital initially show promise as predictors in Model 1 where adequacy of care increases with education (excepting the adequate+ category) and decreases with prior fertility. Yet, these indicators are not signi®cant in Model 2. The only human capital variable that approaches signi®cance for any contrast is age for the adequate+ category. Similarly, the odds ratio for those who live more than a half hour away from their mother approaches signi®cance for the adequate+ contrast, but neither union status nor proximity to one's mother play much of a role in prenatal care utilization. Instead, Models 2 and 3 suggest that emotional sup12

Multivariate models for the Adequacy of Prenatal Care Utilization Index and the most frequently mentioned individual barriers were also examined in the preliminary analysis. These results indicate that those who did not mention ®nancial constraints and lack of awareness as barriers were more likely to receive adequate and adequate+ care. Adequacy of care is unrelated to transportation problems, feeling uncomfortable in doctor's oces and the desire to keep the pregnancy secret after other covariates are controlled. The bivariate association between adequacy and being unsure about carrying the pregnancy to term is replicated in the multivariate analysis. These results are available on request.

1735

port may have an e€ect on securing adequate care. This e€ect does not extend to the adequate+ category. Lifestyle indicators are generally not important for prenatal care utilization either, but two counterintuitive exceptions should be noted. In multivariate models, women who smoked were less likely than women who did not smoke to receive adequate+ care. This is surprising given the linkage between smoking and negative birth outcomes. As for stressful events, women with one stressful event were more likely than those without stressful events to receive intermediate and adequate levels of care. Experience with multiple stressful events was inconsequential. As for the medical risk factors, we see that prenatal care is not associated with medical complications and that the pattern for negative outcomes during previous pregnancies is consistent with expectations. In Model 2, those who had negative outcomes in the past were more likely than those without negative outcomes to receive adequate+ care (contrary to Model 3). This is consistent with the role of prenatal care in monitoring high-risk pregnancies. The odds ratio for the inadequate±intermediate contrast is also borderline signi®cant, but it is less than unity (0.64, p < 0.10). Thus, risks for those with previous negative outcomes tend to be bifurcated into the inadequate and adequate+ categories. We also explored the issue of whether inferences are sensitive to how the multivariate model is speci®ed in a supplementary analysis. This is especially important for multivariate models that include barriers. Barriers could serve as an intervening variable that is responsible for reducing other associations to non-signi®cance. The supplementary analysis indicates that most parameter estimates are not a€ected by the inclusion of barriers in the same model. The exceptions are for number of children and wantedness. Adequacy of prenatal care declines with number of children because mothers with children are more likely to mention barriers to care. As for pregnancy wantedness, all categories are signi®cant for the inadequate±adequate and inadequate±adequate+ contrasts when the number of barriers is excluded. The odds ratios are 0.39 ( p < 0.05) and 0.59 ( p < 0.05) for the inadequate±adequate contrast for women who ``did not want a baby'' and who ``wanted a baby in the future,'' respectively. These ®ndings reinforce the conclusion that both pregnancy wantedness and barriers a€ect prenatal care utilization. Summary and conclusions Puerto Ricans have been singled out for special attention due to their relatively poor infant health outcomes. A fundamental assumption of many health care professionals is that prenatal care plays

1736

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

a critical role in reducing the risk of poor infant health. While existing evidence on prenatal care utilization among Puerto Ricans is consistent with their relatively high rates of negative infant health outcomes, previous studies of prenatal care utilization by Puerto Ricans are hampered by the limitations of vital registration data and non-probability samples. Vital registration data do not include information on a broad range of explanatory factors and non-probability samples su€er from questionable generalizability. Our e€ort to overcome these limitations examined the barriers to prenatal care and the adequacy of care using information from vital records and a survey administered to a representative sample of Puerto Rican mothers in six vital statistic reporting areas. The descriptive objective of this study was to document the prevalence of barriers to prenatal care utilization and the adequacy of prenatal care utilization. Our results indicate that adequate prenatal care is not universal Ð approx. 56% of our respondents had ``adequate'' levels, 25% had ``intermediate'' levels and 20% obtained ``inadequate'' levels of care. Moreover, barriers to prenatal care utilization are common even though no one single barrier predominates. Half (48%) of the respondents mentioned at least one barrier and one-®fth (22%) mentioned at least two types of barriers that made it dicult for them to get care. Among the most frequently mentioned barriers are those that signal uncertainty about the pregnancy: the consideration of abortion, the desire to keep the pregnancy secret and the lack of awareness of the pregnancy. Monetary and transportation problems also cannot be 13 The conclusions regarding perceived ®nancial problems are not necessarily inconsistent with those for ®nancial capital (see below). 14 Because wantedness allegedly emanates from the ®t between a new child and the environment necessary to support him/her, we examined the possibility that wantedness is a potential intervening variable in the relationships between prenatal care and various forms of capital and lifestyles. Wantedness, for example, might explain the lack of signi®cance of income. The results are not sensitive to the exclusion of wantedness from the full model for the Prenatal Care Utilization Index in Table 4. 15 Such ®ndings support previous assessments of the fundamental importance of psychological circumstances surrounding the pregnancy. However, future studies must expand the barriers under consideration to capture the full range of experiences of Puerto Ricans on the mainland. In particular, perceptions of discrimination in the health care system must be examined. A related need is for studies that focus on the perceived bene®ts to care. Beliefs about what is ``gained'' from seeing a prenatal care provider may play a role in overcoming various barriers.

ignored, but aspects of the health care delivery system are relatively minor in importance. This inventory of the most frequently mentioned barriers to prenatal care is an important ®rst step in determining strategies for increasing access to medical care. The second step is to determine whether adequacy of care and various barriers are related. If potential targets for intervention are the barriers that occur frequently and have a nontrivial relationship with adequacy of care, then those that indicate the psychological circumstances surrounding the pregnancy (e.g. the desire to keep the pregnancy secret), pregnancy awareness and discomfort at doctors' oces should receive attention along with ®nancial problems13. The analytic objective focused on the etiology of prenatal care utilization, with a theoretical discussion that drew attention to the number of barriers, migration, di€erent forms of capital, lifestyles, medical risks, and pregnancy wantedness. The odds ratios indicate that the number of barriers and pregnancy wantedness are among the most important predictors of prenatal care utilization. Barriers and unwanted pregnancies impinge on the ability to obtain adequate levels of prenatal care14 15. Moreover, these ®ndings are consistent with the negative association between fertility and adequacy of care in models that exclude barriers. High fertility increases the chance of facing barriers and thereby reduces the adequacy of utilization. Collectively, these results suggest that e€orts to foster greater control over fertility will have positive repercussions for prenatal care utilization. Employment is a major socioeconomic determinant of prenatal care utilization. Employed women are less likely than women who are not employed to mention barriers to care (Model 1) and more likely to have adequate levels of prenatal care utilization (Models 1, 2 and 3). The latter ®nding is especially noteworthy because economic explanations of employment e€ects emphasize the importance of jobs for contributing to household income and providing health insurance to workers. Those with (``good'') jobs may obtain health insurance which, in turn, provides access to the highest levels of care. While health insurance may facilitate the receipt of care that surpasses ACOG recommendations, the robustness of the parameter estimates for employment in multivariate models suggests that additional explanations are needed. Employment may foster prenatal care utilization by increasing personal ecacy and broadening contacts beyond the intimate circle of family and friends. Co-workers can serve as ``weak'' ties that pregnant women can communicate with about pregnancy and health care. This intimate circle was examined in this study with indicators of social capital. Our results suggest that mothers who have someone to rely on for emotional

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

support and advice are more likely than those who do not have someone to rely on to receive adequate care. This is signi®cant given previous speculation that the underutilization of prenatal care services by Latinas stems from the availability of an alternative health care network comprised of friends and relatives who serve as surrogate providers. On the contrary, ties to others who provide support and advice assist pregnant women in overcoming barriers and in utilizing prenatal care services. Such bene®cial ties are not necessarily restricted to a mother or mother in-law who lives nearby. Proximity to mothers has little e€ect, a ®nding that is consistent with the role of transportation and communications technology in maintaining contact with one's family. Prenatal care utilization is also unrelated to union status, despite the tendency of married women to face fewer barriers to care than single women. Attempts to understand the health-related behaviors of disadvantaged ethnic minorities such as Puerto Ricans frequently focus on the stresses and strains that are associated with poverty, including incarceration, debt and violence. Indeed, our analysis indicates that this emphasis is not necessarily misdirected Ð stressful life circumstances during pregnancy create barriers to prenatal care. However, the extension of this ®nding to prenatal care utilization is not straightforward. Contrary to expectations, adequacy of care is greater among those who experience a single stressful event than those who experience no stressful events. In addition, smokers are less likely than non-smokers to receive adequate+ care. Smokers do not receive greater monitoring from prenatal care providers due to their increased risks of negative infant health outcomes. Among medical risks, both barriers and adequate+ prenatal care utilization are associated with negative outcomes for prior pregnancies. Negative outcomes in the past are an indication to monitor a pregnancy closely (notwithstanding the results for Model 3). The lack of empirical support for several hypotheses must be noted as well. While the migration hypothesis posits that migrants utilize the health care system less than non-migrants, island-born and mainland-born Puerto Ricans do not di€er in the number of barriers to prenatal care or their utilization of prenatal care. Additional analyses were also conducted to investigate this issue further (not shown). The ®rst analysis examined the possibility that migration conditions the e€ects of other variables. Tests for interactions 16 As of mid 1996, approx. 1.05 million persons were enrolled Medicaid on the island (American Academy of Paediatrics [http://www.aap.org/advocacy/stenroll.html]). The total island population in 1990 was 3.5 million.

1737

between migration and other key covariates were not signi®cant. The second analysis examined the possibility that variation in prenatal care utilization among migrants is a function of exposure to the US. Using migration histories to calculate the total number of years of residence on the mainland, this supplementary analysis indicates that cumulative exposure to the US among migrants is not a signi®cant predictor in bivariate or multivariate models for either dependent variable. Obviously, these ®ndings may not be generalizable to other migrant groups that face barriers due to lack of citizenship and their origination in countries without developed health-care infrastructures. Puerto Rican migrants are US citizens (by birth) who come from a setting that is already well integrated into the Medicaid program16. This latter point directs attention to the potential value of research that compares those who migrate to the mainland with those who remain behind in Puerto Rico. Another important non-®nding is the lack of support for the ``income hypothesis''. To speculate, this non-®nding may stem from imperfect measurement. Financial constraints may not be adequately captured by household income. Household income measures the in¯ow of resources to the household unit, but ®nancial constraints re¯ect wealth and/or net worth. This implies that quantitative information on ®nancial assets and liabilities (debts) would greatly aid e€orts to understand the economics of utilization. In addition, assumptions about universal access to household resources must be examined. Lack of control over discretionary income may be the crucial factor that impinges on the ability of some pregnant women to secure adequate care. Thus, alternative measures of ®nancial constraints and control over resources should be examined in future studies. Measurement challenges also exist for prenatal care. The Prenatal Care Utilization Index is a major improvement over measures that focus just on the month of initiation or frequency of visits because it utilizes information on accepted standards for the initiation of prenatal care and the appropriate frequency of care by gestational age. Two caveats are that information on prenatal care visits from vital records may be inaccurate for some women (including those who move and/or change providers) and the adequacy of care should not be confused with the quality of services received. The quality of services received cannot be determined from vital records or from interviews alone. Studies that are able to overcome these limitations promise to provide a more complete picture of prenatal care utilization. In closing, the United States is faced with a series of profound challenges as the twentieth century draws to a close. Perhaps the biggest challenge is to reduce the roles of race and ethnicity in structuring the life

1738

R.S. Oropesa et al. / Social Science & Medicine 51 (2000) 1723±1739

chances of individuals, particularly insofar as the chances for a healthy life are concerned. Indeed, ``racial and socioeconomic inequality in health is arguably the most important public health issue in the United States'' (Williams & Collins 1995, p.381). It is with this broad set of concerns that Puerto Ricans are identi®ed as a group in need of special attention because of relatively inadequate prenatal care utilization and poor infant health outcomes. Our results caution against reducing the problem of prenatal care utilization to economics or migrant adjustment. Rather, a thorough understanding of prenatal care utilization among mainland Puerto Ricans requires an extension of our analytic focus to the social and psychological circumstances that surround pregnancies.

Acknowledgements This research was supported by a grant from the National Institute of Child Health and Human Development (Grant R01 H232331-05). Data collection was funded by NICHD, the Maternal and Child Health Bureau and the Centers for Disease Control. The data were collected by the Institute for Survey Research at Temple University under a subcontract from the Pennsylvania State University. Support services were provided by the Population Research Institute, The Pennsylvania State University, which has core support from NICHD Grant 5 R01 HD28263-07. The authors appreciate the comments of the anonymous referees and the data management skills of Cynthia Mitchell and Jeanne Spicer.

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