Nonuse of Prenatal Care Implications for Social Work Involvement

A qualitative study of reasons for nonuse of prenatal care was conducted over a 10-month period in 1988 and 1989. Through personal interviews with 44 women who did not obtain prenatal care, four categories of reasons for nonuse were identified: (1) the women's lifestyles different from mainstream society, (2) the women believed prenatal care was important, but stressful events In their lives took priority; (3) the women attempted to receive care but were discouraged, turned away, or given poor information by service delivery system personnel; and (4) the women did not want the baby. These reasons clearly indicate a need for social services intervention. Health and social sciences research demonstrates that adequacy of prenatal care has a direct relationship to pregnancy outcome (Alan Guttmacher Institute, 1985; American Public Health Association, 1985; Green, 1981; Lewin, 1985). Adequate prenatal care begins in the first trimester and continues on a regular schedule until delivery. Lack of adequate prenatal care is associated with poor pregnancy outcomes, including high rates of infant and neonatal death, premature birth, birth defects, maternal death, and birth complications (Brann, 1981; Lawrence, 1988). Demographic studies indicate that the typical nonusers of prenatal services are black women, teenage girls, women with more than four previous births, single women, poor women, and women with less than a high school education (Alan Guttmacher Institute, 1985; Cramer, 1987; Green, 198 1; Select Committee on Children, Youth, and Families, U.S. House of Representatives, 1987; U.S. Department of Health and Human Services, Center for Vital Statistics, 1988). Most of these descriptors indicate that multiple problems, in addition to nonuse of prenatal care, may affect pregnancy outcome and postnatal care of the baby. Nevertheless, during the past two decades, local, state, and federal programs have attempted to improve pregnancy outcome statistics almost solely through efforts to make prenatal care programs affordable and accessible. Despite substantial funding, vital statistics continue to show that a significant number of women do not obtain adequate prenatal care. This study was designed to more fully describe this population to make recommendations for service approaches. Literature Review Most studies of nonuse of prenatal care either assess prenatal program effectiveness in reducing poor pregnancy outcome or identify demographic characteristics of nonusers of services. To date, few studies have addressed reasons for nonuse of prenatal care. Bracken (1968) used a structured questionnaire, based on demographics identified in vital statistics, to interview 228 maternity patients in metropolitan Salt Lake City. This study showed that lower levels of education and lack of understanding of need for care were associated with lack of adequate prenatal care, and financial ability and transportation and child care availability were associated with use of prenatal care. Berns (1982) studied 10 Indianapolis women who arrived at Community Hospital with no previous prenatal care. The women's level of pregnancy denial was so high that they professed either no awareness or a slight suspicion of pregnancy up to the time of delivery. After the birth, the women immediately requested the adoption of their babies. A retrospective study of 43 nonusers of prenatal care was conducted by hospital social workers (Joyce, Diffenbacher, Greene, & Sorokin, 1984) at Cleveland Metropolitan General/Highland View Hospital during 1978. The sample was composed of almost equal numbers of white and nonwhite women. Eighty-one percent of the women had their medical expenses paid by the county welfare department. Reasons charted for nonuse were categorized as internal barriers such as depression or denial (20 women) and external barriers such as lack of money, transportation, and child care (10 women); 13 women said they felt fine and saw no need for care. …