Barriers and motivators to prenatal care among low-income women.

Substantial evidence exists which links prenatal care to improved birth outcomes. However, low-income and nonwhite women in the United States, who are at greatest risk for poor birth outcomes, continue to receive the poorest prenatal care. The purpose of this study was to identify and compare barriers and motivators to prenatal care among women who lived in low-income census tracts. The stratified sample included recently delivered white, black and American Indian women who received adequate, intermediate, and inadequate prenatal care. Interviews were conducted which focused primarily on the women's perceptions of problems in obtaining prenatal care and getting to appointments. Results indicated that women with inadequate care identified a greater number of barriers and perceived them as more severe. Psychosocial, structural, and socio-demographic factors were the major barriers, while the mother's beliefs and support from others were important motivators. The predictive power of selected barrier variables was examined by a regression analysis. These variables accounted for 50% of the variance in prenatal care use. The results affirm the complexity of prenatal care participation behavior among low-income women and the dominant influence of psychosocial factors. Comprehensive, coordinated and multidisciplinary outreach and services which address psychosocial and structural barriers are needed to improve prenatal care for low-income women.

Prenatal care comparisons among privately insured, uninsured, and Medicaid-enrolled women.

Women without health insurance and those covered by Medicaid have been shown to obtain prenatal care later in pregnancy and make fewer visits for care than do women with private insurance. Factors that keep women from obtaining care include inadequate maternity care resources, difficulty in securing financial coverage, and the psychosocial issues of pregnancy. This study identified and compared prenatal care use patterns, insurance coverage changes, and psychosocial factors among 149 women in Minneapolis, MN, with private health insurance, Medicaid, and no health insurance. Little information has been available on the insurance status of women at the start of pregnancy and the paths subsequently taken to obtain financial coverage for prenatal care.

The Minnesota Prenatal Care Coordination Project: successes and obstacles.

The Minnesota Prenatal Care Coordination Project was a statewide effort to present systematically education and technical support to providers as they implemented the Minnesota Prenatal Care Initiative for expanded services to high-risk women. Educational methods included holding 12 regional workshops throughout the State, one-to-one contacts by nurse consultants, and newsletters and a guidebook (manual) were distributed to reach community providers. Analysis of the implementation was conducted using site visits, interviews with providers, and reviews of medical records, claims data, and other project documents. Successes in the first year were a twofold increase in the numbers of Medicaid-enrolled women who received risk assessment and enhanced services, more than one-third increase in provider participation, greater collaboration among multidisciplinary providers at the community level, and improved communication between State and local health care agencies. Obstacles included provider resistance to changes in practice, dissatisfaction with the enhanced services package and level of reimbursement, and problems with implementation protocols. The project demonstrated that prenatal care providers will change; they will improve practices and collaboration as a result of personalized education and support.

Prenatal care use and health insurance status.

Many observers explain the prevalence of inadequate prenatal care in the United States by citing demographic or psychosocial factors. But few have evaluated the barriers faced by women with different health insurance status and socioeconomic backgrounds. In this study of 149 women at six hospitals in Minneapolis, insurance status was significantly related to the source of prenatal care (p less than .0001). Private physicians cared for 52 percent of privately insured, 23 percent of Medicaid-insured, and two percent of uninsured women. Public clinics were the primary source of care for Medicaid and uninsured women, who, compared to privately insured women, experienced longer waiting times (p less than .001) during prenatal visits and were more likely (p less than .01) to lack continuity of care with a provider. Multiple measures, including expanding Medicaid eligibility, may help correct these problems.

Effects of social support on prenatal care and health behaviors of low-income women.

OBJECTIVE: To determine the relationship of social support from partners and others to the adequacy of prenatal care and to the prenatal health behaviors of low-income women. DESIGN: Descriptive, correlational study using self-reports and medical record review. SETTING: Data were collected in five metropolitan prenatal clinics serving low-income women. PARTICIPANTS: Ethnically diverse, primarily single, low-income pregnant women (N = 101) between 28 and 40 weeks of pregnancy. MAIN OUTCOME MEASURES: Subjects completed the Norbeck Social Support Questionnaire, the Prenatal Health Questionnaire, and the Demographic/Pregnancy Questionnaire. RESULTS: Social support provided by the partner correlated positively with adequacy of prenatal care, whereas social support from others (excluding partner relationships) correlated positively with prenatal health behaviors. Professionals such as health care providers and counselors were not considered sources of social support by women. CONCLUSIONS: Nurses who work with low-income pregnant women in a variety of settings should assist partners in recognizing their potential positive contributions, teach women to communicate their expectations to their partners, acknowledge the importance of other family members as providers of social support, and when needed, refer women to programs that increase available social support.

Antepartum home-care services for high-risk women.

OBJECTIVE: To determine the scope of home-care services for pregnant women by addressing types of agencies, nursing personnel, and problems encountered. DESIGN: Descriptive study with survey questionnaire. SETTING: A sample of urban and rural settings throughout Minnesota. PARTICIPANTS: Nine private and 38 public agencies providing antepartum home-care services. MAIN OUTCOME: Data described clients, agencies, personnel, and services. RESULTS: Differences were reflected in the nursing skills and interventions used with high-risk pregnant women. Public agencies identified teenage pregnancy as the most frequent antepartum problem, while private agencies identified preterm labor. CONCLUSION: Results suggest a need to examine the scope of antepartum home-care services.

First family planning visit in school-based clinics.

The timing of the first family planning visit for 144 female adolescents using school-based clinics in four St. Paul, Minn., high schools was studied. Mean delay time for the sample was 11.4 months and the median was 7.8 months. Almost 50% of the sample arrived within two months of either a planned onset of sexual intercourse (virgin group) or a recent start of sexual activity (short delay group). Early onset of sexual activity (v age 15) was more prevalent among long delayers (47.9%) than among short delayers (21.1%). Longer delayers were more likely to come from the lowest socioeconomic groups. Short delayers and longer delayers were equally likely to have been motivated to attend the clinic because they feared they were pregnant. Reasons for choosing this clinic over others reflected the importance of confidentiality, comprehensiveness of services, and the specific adolescent orientation of care.

An interdisciplinary health team training program for school staff in Minnesota.

This paper describes an interdisciplinary health team training program for school-based clinic staff in Minnesota. The project sought to improve team functioning, level of practice, and health care services at the school sites. Participants were interdisciplinary staff members from clinics in senior high, middle, and elementary schools. The program consisted of further development in team training knowledge and skills and educational sessions on issues identified by participants. Evaluations indicated participants reported greater knowledge and improved team functioning experiences from the team training. Gains also were shown in knowledge and skills in specific school topic areas such as violence, resiliency, working with resistant families, and self-care. The program could serve as a model for other interdisciplinary school health team training.

A partnership model of distance education: students' perceptions of connectedness and professionalization.

This article describes a partnership model of distance education for a master's nursing program in a midwestern state and an evaluation that assessed students' perceptions of professionalization and connectedness in the program. Students at the originating and distance sites were asked to complete evaluations at the end of each course. Connectedness and professionalization were measured using rated satisfaction with three modes of contact for each item. Results indicated that students at the distance site had a significantly higher overall level of satisfaction with interactive television (ITV) and experienced high levels of connectedness and professionalization through the ITV courses. However, among the three modes of connectedness, students at the distance site rated satisfaction with contact with same-site students as the highest, followed by contact with the instructor. Students also perceived that their professional identity increased through the three modes, particularly for contact with same-site peers at the distance site and for contact with instructors at both sites. Recommendations for faculty and student responsibilities are provided to ensure a positive learning environment.

Comparison of professional activities of nurse doctorates and other women academics.

This study compared professional activities of nurse doctorates with those of academic women doctorates in other disciplines. The Biographical-Professional Activities Questionnaire, completed by 219 respondents, assessed biographical data and six faculty indexes: primary academic function, percentage of time devoted to specific academic functions, professional publications, research grants received, consultation, and professional meetings attended. The findings indicated that teaching was the primary academic function for both groups, academic women spent significantly more time on research activities and published more journal articles, and nurse doctorates spent more time on administrative activities. Few other significant differences were found between nurse-doctorate faculty and other academic women in these research institutions when controlling for years since doctorate.

Prenatal care in northwestern Wisconsin.

The purposes of this study were to identify the components of prenatal care given by family practice physicians and obstetricians in a rural area and determine whether they were in agreement with standards of care advanced by the American College of Obstetricians and Gynecologists (ACOG). We surveyed 76 physicians (family physicians with and without residency training and obstetricians) and identified 40 components of regular prenatal care; they were consistent with 94% of the ACOG recommendations. Few differences were found in prenatal care practices by type of family practice training. Although the number of obstetricians was small, these specialists appeared more likely to agree with ACOG guidelines. Risk assessment instruments were not routinely used by most physicians, and the services of public health nurses were not generally recommended as part of prenatal care. The findings have implications for continuing medical education programs.

Parental concerns of Mexican American first-time mothers and fathers.

The purpose of the study was to identify the parental concerns of Mexican American first-time mothers and fathers using an ethnographic approach. The study was conducted for 10 months in Hidalgo County, Texas. Twenty-six families were followed longitudinally during their first 6 months of parenting with an average of eight (SD = 1.8) home visits per family. Audio-taped conversations with participants were transcribed verbatim in their entirety in either Spanish or English. Spanish transcripts were translated and checked for accuracy by a local consultant. Salient parental concerns derived from content analysis were infant illness, providing for the material needs of the infant, threats infants face in the future, knowing how to rear an infant, and facing job loss. Public health nurses can collaborate with parents by working from expressed concerns to enhance family health and the health of the local community.

Family ritual facilitates adaptation to parenthood.

An ethnographic study done in Hidalgo County, Texas, among 25 Mexican American first-time mothers and fathers documented the presence of an intergenerational family ritual that facilitated adaptation to parenthood in 24 of the 25 families. La cuarentena is a family ritual of 40 days duration postbirth with cultural prescriptions for maternal food and clothing and for paternal role reversal. La cuarentena instills parental responsibility, incorporates individuals into the family, and integrates the family during this critical life-event of first birth. A thorough understanding of la cuarentena will assist nurses to enhance adaptation to parenthood for Mexican American parents.

Public health nursing practice guidelines: an evaluation of dissemination and use.

Public health nursing needs to build a practice on research-based knowledge. Public health guidelines are one strategy to achieve this goal. Using research-based knowledge, the Minnesota Practice Enhancement Project (MPEP) developed positive parenting and family violence prevention guidelines for public health nurses (PHNs). The purpose of this study was to evaluate the dissemination and use of the MPEP guidelines using a survey of PHNs and telephone interviews of public health nursing directors. Results indicated that respondents viewed the guidelines as important, but identified numerous barriers to integrating the guidelines into their practice. Major barriers included lack of time in their work day, complex guideline structure, and competing agency demands and priorities. Findings were consistent with Roger's Diffusion of Innovations theory, which describes factors associated with the adoption of a new idea or practice. Recommendations for effective dissemination include administrative support and structure to increase PHN intentional use of practice guidelines, a simplified guideline format, and mentorship in guideline use.

Community interdisciplinary education to promote partnerships in family violence prevention.

Family violence is a major social and health problem in the United States. Educational approaches are needed that help professionals and communities develop more effective skills to work with families and communities. This article describes a statewide, interdisciplinary, community-based educational program for professionals and paraprofessionals and a 6-month post-evaluation. Participants reported knowledge and skill development in assessment and interventions, improved use of violence prevention data for planning and interventions, and increased community partnerships and collaborations. Recommendations address violence prevention leadership, funding, infrastructure, interdisciplinary professional education, greater community awareness, and policy development.

Medicaid and non-Medicaid prenatal care by nurse-midwives. Comparison of risk, time, care coordination, and reimbursement.

The purpose of the study was to compare high-risk pregnant women with medical assistance payment (HRMA) and those with private insurance payment (HRPI) on use of provider time, care coordination activities, and financial reimbursement. Comparisons were also conducted for the same factors between the high-risk and low-risk women (LRMA) that received medical assistance payment for their care. Total time spent by care providers in giving antepartum, intrapartum, and postpartum care was highest for the HRPI women. However, the two medical assistance groups started prenatal care significantly later and had fewer visits, and one-third did not return for their 6-weeks postpartum visit. The HRPI group also had a higher cesarean birth rate. Rates of care coordination activities such as calls, referrals, and consultations were significantly higher for the HRPI and HRMA women compared with those for the LRMA women. However, the HRMA women have limited financial and psychosocial resources that require additional provider management and referrals. Reimbursement rate was highest for the HRPI group in which approximately 73% of the total amount billed was collected compared with approximately 56% among medical assistance women. Recommendations for policy, practice, and further research are offered.

Population-based public health nursing interventions: a model from practice.

In a changing and complex health care system, public health nurses face challenges to explain their work and contributions to health outcomes. In response to this need, the Minnesota Department of Health, Section of Public Health Nursing, initiated a process to describe public health nursing interventions. The Public Health Nursing Interventions (PHI) Model was developed through a collaborative process by public health nurses at the state and local levels. The purpose of the model was to define more clearly the practice of public health nursing and to describe better the work of public health nurses at the community and systems levels. The PHI model identifies 17 interventions and provides practice examples at the systems, community and individual/family levels. The model defines a broader view of the mission and scope of public health nursing. Practice examples are given for agency staff, administrators, educators, and policy makers.

Fulfilling regional needs for specialty nurses through limited-cohort graduate education.

The University of Minnesota has developed a limited-cohort distance education graduate program to overcome geographic barriers and address the shortage of master's-prepared specialty nurses in rural areas of the upper Midwest. Such a program offers graduate nursing education in various specialty areas to distance sites for a predetermined, relatively short period.