Disparity in prenatal care among women of colour in the USA
Introduction
According to the US Census in 2000, people of colour, called non-whites, comprised 29% of the US population and will be greater than 50% by 2060 (OMH, 2004). The people of colour represent Hispanic or Latino, African–American, Asian, American–Indian, Alaska native and other non-whites (Declercq et al., 2001). About 4 million babies were born in the USA in 2001 (Martin et al., 2002). Of those births, 42% were births to women of colour. The number of babies born to women of colour has steadily increased from 35% in 1989 to 42% in 2001 (Ventura et al., 1999; Martin et al., 2002). Given the current rate of growth, the anticipated number of births to women of colour should exceed 50% by the year 2020. Considering the increased proportion of births to women of colour, special attention is needed to detail birth outcomes for these populations.
In the past few years, much focus has been placed on decreasing disparities in health care by improving the quality of care delivered, and by improving access for people of colour (Glinzberg, 1991; Lieu et al., 1993; Phillips et al., 2000). The criteria for good prenatal care are as follows: The US Public Health Care Services establish the standard of prenatal care that encourages pregnant women in the USA to initiate prenatal care in the first trimester (US Department of Health and Human Services [USDHHS], 2000). The American College of Obstetricians and Gynecologists (ACOG) traditionally recommends about 14 prenatal visits to low-risk pregnant women (American College of Obstetricians and Gynecologists, 1997). A reduced-frequency prenatal visit schedule, about eight visits, is also advised to low-risk pregnant women, because studies show that no significant differences in perinatal outcomes exist between the eight-visit schedule and the 14-visit schedules (McDuffie et al., 1996; Walker et al., 2002). In this study, however, good prenatal care is defined as initiating prenatal care in the first trimester, which results in about 14 prenatal visits for these low-risk women.
The US Public Health Care Services made substantial efforts to improve access to care, which has resulted in significantly improved rates of prenatal care over the past 2 decades (Cunningham et al., 2001). Between 1980 and 2001, the rate of women who began prenatal care in the first trimester of pregnancy has improved from 76.3% to 83.4% (Martin et al., 2002). Additionally, the rate of women who received late care (care beginning in the third trimester) or no prenatal care decreased from 6.1% to 3.7% from 1990 to 2001.
Although overall national rates of early prenatal care improved, there remains considerable discrepancy between non-Hispanic white and non-white women's timely access to prenatal care, which is a significant indicator of birth outcomes (Martin et al., 2002). For example, in 2001, 88.5% of non-Hispanic whites received early prenatal care, whereas only 69.3% of American Indian women received early prenatal care. In addition, late or no prenatal care rates were two times higher among African–American and Hispanic women than for non-Hispanic white women. Only 2.2% of non-Hispanic white women failed to receive prenatal care or received late care, whereas 6.5% of African–Americans and 5.9% of Hispanics accessed prenatal care late or went without care (Martin et al., 2002). This disparity in prenatal care rates leads to a discrepancy in birth outcomes, such as low birth weight, preterm birth, and infant mortality, between non-Hispanic white and non-white women (Alexander and Cornely, 1987a; Hogue and Vasquez, 2002; Vintzileos et al., 2002; Hamilton et al., 2003; Herbst et al., 2003; Leslie et al., 2003).
Disparities in birth outcomes are especially significant to midwives who tend to care for a disproportionate number of underserved and vulnerable women (Rorie et al., 1996; Paine et al., 2000; Declercq et al., 2001; Martin et al., 2002). Studies show that midwives are likely to serve demographically diverse populations, including women who are immigrants, uninsured women, adolescents, and non-whites (Parker, 1994; Declercq et al., 2001). Additionally, national findings suggest that midwives provide birth services for more women of colour than do physicians (Ventura et al., 1999; Martin et al., 2002).
Although midwives are more likely to serve vulnerable women who are at risk for poor birth outcomes (Paine et al., 1999; Paine et al., 2000; Declercq et al., 2001; Walker et al., 2002), only 8.6% of midwifery research studies between 1984 and 1998 in the USA were related to vulnerable populations, including two research studies that studied specific ethnic groups (Raisler, 2000). Further examination is needed to identify factors that influence access to care, especially for women of colour.
Because a goal of the US Public Health Care Services is to promote early (in the first trimester) and regular prenatal care for all pregnant women, and because of the disparities in birth outcomes in different ethnic groups (Hogue and Vasquez, 2002; Vintzileos et al., 2002; Hamilton et al., 2003; Herbst et al., 2003), a study was conducted to examine prenatal care in a select population. In this study, timing of the initiation of prenatal care and total number of prenatal visits—both indices of adequacy of prenatal care (Alexander and Cornely, 1987b) and closely related to birth outcomes—were examined in relation to demographic variables. Findings were compared with national data (Ventura et al., 1999; Martin et al., 2002). Specifically, this retrospective, secondary analysis sought to examine the following research questions: (1) is there a difference in the total number of prenatal visits based on varying demographics, including race, education, age, marital status, method of payment and clinical sites?; and (2) is there a difference in the timing of initiation of prenatal care based on varying demographics, including race, education, marital status, method of payment and clinical sites?
Section snippets
Design and setting
The purpose of this retrospective descriptive study was to analyse relationships between the women's characteristics and the number of prenatal visits and onset of prenatal care. The study was a secondary analysis of a larger investigation, examining nurse–midwifery outcomes. Data were obtained using the Nurse–Midwifery Clinical Data Set (NMCDS), and were collected from 1996 to 1997. This was the most recent time period for which practice data existed, and it provided a rich repository for
Participants
The study sample comprised healthy women at term (37–42 weeks gestation) with a vertex singleton pregnancy and an essentially uncomplicated prenatal course. Prenatal care was provided at one of five clinics, with most women receiving care by the same nurse–midwives who provided birth services. Nurse–midwives provided care on a rotational, assigned basis. One clinic was housed at the university facility and provided full-scope services. The other four clinics were all outside the university in
Demographic characteristics
The total sample consisted of 439 participants. The demographic characteristics are shown in Table 1. Nearly two-thirds (61.6%) of the sample comprised non-whites (). This group included Hispanic, African–American, Asian, Native American and women who described themselves as ‘other’. More than 90% of non-whites in this study consisted of Hispanic or African–American. Non-Hispanic white accounted for 38.4% of the sample ().
The sample almost equally consisted of women with less than a
Discussion
The limitation of this study is that only 439 participants receiving prenatal care by midwives were analysed. This study has a comparatively small sample, and most of the participants were women of colour in low socio-economic conditions. Because this study was conducted in 1997, national survey data from 1997 were examined in order to see the big picture of health disparity in prenatal care. The 1997 national data set was compared with the most recent accessible data from 2001. However, data
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