Late Entry into Prenatal Care: The Neighborhood Context

This study investigated individual and neighborhood factors associated with late entry into prenatal care. Data from 220,694 New York City birth certificates were linked with data from the 1990 census and other secondary sources to determine the effect of women's individual characteristics and their neighborhood context on timing of prenatal care entry. Results indicate that 15 percent of New York City's pregnant women entered prenatal care late and that residence in a distressed urban neighborhood significantly increased the risk of late initiation, even in a model controlling for individual risk factors. Implications for social workers include the importance of outreach and case management for pregnant women, the value of health and social policies targeting distressed urban neighborhoods, and the need to ensure that Medicaid managed care implementation fosters use of prenatal care. The findings also underscore the importance of continuing to strive for a policy that ensures lifelong universal access to health care. Key words: health policy; managed care; prenatal care; urban health The viewpoint commonly taken by social workers stresses the importance of giving full consideration to the ways in which the social environment influences the behavior of individuals. Indeed, the theoretical and value bases of the profession are distinguished in their commitment to considering the individual in his or her social context, to identifying environmental factors that contribute to social problems, and to modifying the social environment as a means of battling social problems. Although social work's theoretical frameworks often posit a range of individual and con textual influences on behavior, much empirical research tends to overlook the ways that social context shapes and maintains behavior and the social problems that can result. Rarely do practitioners have the data they need to describe individuals and the key elements of their social environment adequately. Most often, when these multiple levels of data are available (as might be the case, for example, in a qualitative inquiry), social workers lack a sufficient number of cases to test a complex multivariate statistical model. Challenges such as these can make the use of a multilevel theoretical framework difficult, if not impossible. This shortcoming is evident in the research on factors influencing the use of prenatal care. Early prenatal care is widely regarded as important because it provides social workers and other health professionals with opportunities to identify pregnant women who are at risk of premature or low-weight births and to deliver the medical, nutritional, educational, or psychosocial interventions that can promote positive pregnancy outcomes (Kiely & Kogan, 1994). Despite prenatal care's potential to improve birth outcomes, however, 21 percent of U.S. women begin prenatal care after the first trimester of pregnancy. Rates of late entry into care are even higher among teenagers and members of racial and ethnic minority groups (U.S. Department of Health and Human Services, 1996). Although inadequate use of prenatal care is regarded as an important social problem, most research on the use of prenatal care has focused on individual-level factors rather than on environmental or contextual factors that influence women's use of services. These studies, reviewed in recent years by the Institute of Medicine (Brown, 1988), Goldenberg, Patterson, and Freese (1992), and Kiely and Kogan (1994), have focused primarily on identifying key characteristics such as age, race, knowledge, or attitudes that place individual women at high risk of late entry into prenatal care. The literature acknowledges the influence of social context on service use, but few studies have examined the influence of contextual factors--including family members, friends, and communities--on women's use of prenatal care. In keeping with social work's ecological perspective (Germain, 1991), the study reported in this article views women's health services use as a function of the individual and the social environment. …