Explanatory factors for first and second-generation non-western women's inadequate prenatal care utilisation: a prospective cohort study.

BACKGROUND: Little research into non-western women's prenatal care utilisation in industrialised western countries has taken generational differences into account. In this study we examined non-western women's prenatal care utilisation and its explanatory factors according to generational status. METHODS: Data from 3300 women participating in a prospective cohort of primary midwifery care clients (i.e. women with no complications or no increased risk for complications during pregnancy, childbirth and the puerperium who receive maternity care by autonomous midwives) in the Netherlands (the DELIVER study) was used. Gestational age at entry and the total number of prenatal visits were aggregated into an index. The extent to which potential factors explained non-western women's prenatal care utilisation was assessed by means of blockwise logistic regression analyses and percentage changes in odds ratios. RESULTS: The unadjusted odds of first and second-generation non-western women making inadequate use of prenatal care were 3.26 and 1.96 times greater than for native Dutch women. For the first generation, sociocultural factors explained 43% of inadequate prenatal care utilisation, socioeconomic factors explained 33% and demographic and pregnancy factors explained 29%. For the second generation, sociocultural factors explained 66% of inadequate prenatal care utilisation. CONCLUSION: Irrespective of generation, strategies to improve utilisation should focus on those with the following sociocultural characteristics (not speaking Dutch at home, no partner or a first-generation non-Dutch partner). For the first generation, strategies should also focus on those with the following demographic, pregnancy and socioeconomic characteristics (aged ≤ 19 or ≥ 36, unplanned pregnancies, poor obstetric histories (extra-uterine pregnancy, molar pregnancy or abortion), a low educational level, below average net household income and no supplementary insurance.

Determinants of prenatal health care utilisation by low-risk women: a prospective cohort study.

BACKGROUND: Prenatal health care is pivotal in providing adequate prevention and care to pregnant women. AIM: We examined the determinants of inadequate prenatal health care utilisation by low-risk women in primary midwifery-led care in the Netherlands. METHODS: We used longitudinal data from the population-based DELIVER study with 20 midwifery practices across the Netherlands in 2009 and 2010 as the experimental setting. The participants were 3070 pregnant women starting pregnancy care in primary midwifery care. FINDINGS: We collected patient-reported data on potential determinants of prenatal care utilisation derived from the Andersen model. Prenatal health care utilisation was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and number of visits. Low-risk pregnant women (not referred during pregnancy) were more likely to use prenatal care inadequately if they intended to deliver at a hospital, if they did not use folic acid adequately periconceptionally, or if they were exposed to cigarette smoke during pregnancy. Among those who were referred to secondary care, women reporting a chronic illnesses or disabilities, and women who did not use folic acid periconceptionally were more likely to make inadequate use of prenatal care. CONCLUSION: Inadequate prenatal health care use in primary midwifery care is more likely in specific groups, and the risk groups differ when women are referred to secondary care. The findings suggest routes that can target interventions to women who are at risk of not adequately using prenatal prevention and care services.

"Being flexible and creative": a qualitative study on maternity care assistants' experiences with non-Western immigrant women.

BACKGROUND: Several studies conducted in developed countries have explored postnatal care professionals' experiences with non-western women. These studies reported different cultural practices, lack of knowledge of the maternity care system, communication difficulties, and the important role of the baby's grandmother as care-giver in the postnatal period. However, not much attention has been paid in existing literature to postnatal care professionals' approaches to these issues. Our main objective was to gain insight into how Dutch postnatal care providers--'maternity care assistants' (MCA)--address issues encountered when providing care for non-western women. METHODS: A generic qualitative research approach was used. Two researchers interviewed fifteen MCAs individually, analysing the interview material separately and then comparing and discussing their results. Analytical codes were organised into main themes and subthemes. RESULTS: MCAs perceive caring for non-western women as interesting and challenging, but sometimes difficult too. To guarantee the health and safety of mother and baby, they have adopted flexible and creative approaches to address issues concerning traditional practices, socioeconomic status and communication. Furthermore, they employ several other strategies to establish relationships with non-western clients and their families, improve women's knowledge of the maternity care system and give health education. CONCLUSION: Provision of postnatal care to non-western clients may require special skills and measures. The quality of care for non-western clients might be improved by including these skills in education and retraining programmes for postnatal care providers on top of factual knowledge about traditional practices.

"A mixture of positive and negative feelings": a qualitative study of primary care midwives' experiences with non-western clients living in the Netherlands.

BACKGROUND: Non-western women living in the Netherlands are diverse in origin, which implies diversity in their needs and expectations for midwifery care. Furthermore, it has also been shown that non-western women make suboptimal use of prenatal care. Midwives may therefore face difficulties when caring for these clients. OBJECTIVE: The main objective of our study was to explore Dutch primary care midwives' experiences with non-western clients. METHODS: A qualitative design was used. Thirteen midwives were interviewed individually and 8 participated in a focus group. All interviews were transcribed and analysed by two researchers who compared and discussed their results. Analytical codes were organised into subthemes and main themes. RESULTS: Midwives perceived ethnic diversity as both difficult and interesting. Caring for these women was perceived as demanding, but also rewarding. They experienced a variety of difficulties when caring for these women: communication problems, suboptimal health literacy, socioeconomic problems, lack of knowledge of the maternity care system, pressure from the family and a strong preference for physicians. In spite of these difficulties, midwives aim for optimal care by being alert and proactive, taking these women by the hand and making use of alternative resources. CONCLUSION: Provision of care to non-western clients can be difficult and may require additional measures. These problems and measures should be included in midwifery education programmes as well as training programmes for midwives.

Factors affecting the use of prenatal care by non-western women in industrialized western countries: a systematic review.

BACKGROUND: Despite the potential of prenatal care for addressing many pregnancy complications and concurrent health problems, non-western women in industrialized western countries more often make inadequate use of prenatal care than women from the majority population do. This study aimed to give a systematic review of factors affecting non-western women's use of prenatal care (both medical care and prenatal classes) in industrialized western countries. METHODS: Eleven databases (PubMed, Embase, PsycINFO, Cochrane, Sociological Abstracts, Web of Science, Women's Studies International, MIDIRS, CINAHL, Scopus and the NIVEL catalogue) were searched for relevant peer-reviewed articles from between 1995 and July 2012. Qualitative as well as quantitative studies were included. Quality was assessed using the Mixed Methods Appraisal Tool. Factors identified were classified as impeding or facilitating, and categorized according to a conceptual framework, an elaborated version of Andersen's healthcare utilization model. RESULTS: Sixteen articles provided relevant factors that were all categorized. A number of factors (migration, culture, position in host country, social network, expertise of the care provider and personal treatment and communication) were found to include both facilitating and impeding factors for non-western women's utilization of prenatal care. The category demographic, genetic and pregnancy characteristics and the category accessibility of care only included impeding factors.Lack of knowledge of the western healthcare system and poor language proficiency were the most frequently reported impeding factors. Provision of information and care in women's native languages was the most frequently reported facilitating factor. CONCLUSION: The factors found in this review provide specific indications for identifying non-western women who are at risk of not using prenatal care adequately and for developing interventions and appropriate policy aimed at improving their prenatal care utilization.