Racial disparities in reported prenatal care advice from health care providers.

OBJECTIVES. The relationship between certain maternal behaviors and adverse pregnancy outcomes has been well documented. One method to alter these behaviors is through the advice of women's health care providers. Advice from providers may be particularly important in minority populations, who have higher rates of infant mortality and prematurity. This study examines racial disparities according to women's self-report of advice received from health care providers during pregnancy in four areas: tobacco use, alcohol consumption, drug use, and breast-feeding. METHODS. Health care providers' advice to 8310 White non-Hispanic and Black women was obtained from the National Maternal and Infant Health Survey. RESULTS. After controlling for sociodemographic, utilization, and medical factors, Black women were more likely to report not receiving advice from their prenatal care providers about smoking cessation and alcohol use. The difference between Blacks and Whites also approached significance for breast-feeding. No overall difference was noted in advice regarding cessation of drug use, although there was a significant interaction between race and marital status. CONCLUSIONS. These data suggest that Black women may be at greater risk for not receiving information that could reduce their chances of having an adverse pregnancy outcome.     

Welfare and immigration reform and use of prenatal care among women of Mexican ethnicity in San Diego, California

Foreign-born women and, in particular, Hispanic foreign-born women, are less likely to have insurance, are less likely to have insurance that covers prenatal care, and are less likely to utilize prenatal care compared with US-born Hispanic women. Significant concern has been raised regarding the ability of immigrant women to access prenatal care services because of severe restrictions imposed on immigrants eligibility for Medicaid-funded services following the passage in 1996 of the federal Personal Responsibility and Work Opportunity Reform Act (PRWORA) and the Illegal Immigration Reform and Immigrant Responsibility Act (IIRAIRA). We conducted an interview-based study of prenatal care utilization with women of Mexican ethnicity and diverse immigration statuses in San Diego County, California. Our findings indicate that, despite increased levels of fear associated with recent immigration and with undocumented status, there were no statistically significant differences across immigration statuses in length of time to receipt of medical care for gynecological events and for prenatal care.     

Public and private prenatal care providers in urban Mexico: how does their quality compare?

OBJECTIVE: To evaluate variations in prenatal care quality by public and private clinical settings and by household wealth. DESIGN: The study uses 2003 data detailing retrospective reports of 12 prenatal care procedures received that correspond to clinical guidelines. The 12 procedures are summed up, and prenatal care quality is described as the average procedures received by clinical setting, provider qualifications, and household wealth. SETTING: Low-income communities in 17 states in urban Mexico. PARTICIPANTS: A total of 1253 women of reproductive age who received prenatal care within 1 year of the survey. MAIN OUTCOME MEASURE: The mean of the 12 prenatal care procedures received, reported as unadjusted and adjusted for individual, household, and community characteristics. RESULTS: Women received significantly more procedures in public clinical settings [80.7, 95% confidence interval (CI) = 79.3-82.1; P < or = 0.05] compared with private (60.2, 95% CI = 57.8-62.7; P < or = 0.05). Within private clinical settings, an increase in household wealth is associated with an increase in procedures received. Care from medical doctors is associated with significantly more procedures (78.8, 95% CI = 77.5-80.1; P < or = 0.05) compared with non-medical doctors (50.3, 95% CI = 46.7-53.9; P < or = 0.05). These differences are independent of individual, household, and community characteristics that affect health-seeking behavior. CONCLUSIONS: Significant differences in prenatal care quality exist across clinical settings, provider qualifications, and household wealth in urban Mexico. Strategies to improve quality include quality reporting, training, accreditation, regulation, and franchising.     

Reported cessation advice given to African Americans by health care providers in a community health clinic

Physician smoking cessation advice has been shown to be effective in encouraging patients to attempt cessation. Few studies have examined factors associated with patient-reported physician advice in an inner city community health clinic. Smokers identified via chart review and provider referral met with a study smoking specialist. Eligible participants self-identified as African American, smoked at least 1 cigarette per day in the prior 7 days, were 18 or older, had access to a telephone, and agreed to consider blood testing for genetic susceptibility to lung cancer. Of the 869 smokers identified, 487 were eligible and completed a brief in-person and a more extensive follow-up telephone survey within one week after their visit. Patient reports of smoking cessation advice by providers were regressed on patient demographic, smoking, health, and social support variables. Seventy percent of participants reported that they had been advised to quit smoking. Smokers who were older, did not smoke menthol cigarettes, were in poorer health, and who had a regular health care provider were most likely to report having received advice. Patients in this community health setting reported high rates of provider advice to quit smoking. Yet, even in this optimal condition, young healthy smokers did not report receiving advice, even when they were ready to quit smoking. Providers may need additional training and prompting to counsel young healthy smokers about the importance of cessation.     

中国部分地区孕产妇早孕检查状况及其影响因素

孕早期是胚胎完成各器官、系统、人体外形和四肢发育的关键时期。在孕早期进行检查(早孕检查)可有效地预防孕期合并症和死亡等不良妊娠结局[1]。国外针对早孕检查开展了许多研究[2～5],我国也重视早孕检查并进行了一些研究工作[6～8]。研究发现,我国的早孕检查率从1971年到2003     

玉林社区围产保健现况的调查分析

目的 为了解围产保健服务的需求和现状，探讨提高服务质量、满足需求的先进服务模式和有效方法。方法 于2001年3月按分层整群的抽样方法抽取玉林社区1/10户家庭中在4年内有妊娠史的妇女，共86人，进行入户问卷调查。结果 调查显示：本社区孕妇产前检查的覆盖率为93.9%；围产保健手册建册率为76.1%。产前检查的覆盖率、检查次数及被调查妇女接爱孕期保健的程度与建立围产保健手册呈正相关；产后访视率为52.9%；产前检查服务的满意率为61.0%；产后访视满意率为50.0%。被调查妇女希望改善候诊条件、开设周末门诊并改进医务人员的服务态度。在产后访视方面提出增加访视次数、提早首访时间的建议。结论 玉林社区产前保健已获得较满意的覆盖率，但产后访视率和对服务的满意率尚需进一步提高。应利用社区卫生服务者这一新型服务模式的优势，增强围产保健服务及信息的连续性，进一步提高产后访视率；应加强围产保健档案的科学化、系统化管理，以提高围产保健的依从性。还应在围产保健方面加大健康教育的宣传力度、提高围产保健人员的技术水平和服务意识，为社区居民提供“以人为本”，便捷、质优的围产保健服务。     

Addressing health disparities in highly specialized minority populations: case study of Mexican Mennonite farmworkers

The Kansas Statewide Farmworker Health Program (KSFHP) has developed a unique set of culturally competent health interventions in response to the pressing public health needs of the state’s underserved farmworker population. Key among these are its health education and translation efforts on behalf of the fast-growing Low German-speaking Mexican Mennonite farmworker population. Linguistic, religious, and cultural values have created unique and complex health disparities and barriers to care that can be broken down only through innovative approaches. KSFHP first conducted a health needs assessment survey of the farmworker population in 2003, which indicated prenatal care practices as a significant health disparity, especially among the Low German-speaking Mexican Mennonite population. In response, KSFHP successfully lobbied the state health department to implement a new standard of health behavior data collection that includes primary language data as a method of delineating population subgroups, making Kansas one of the first two states in the country to collect this information. KSFHP also developed culturally competent Low German-language recordings on health topics such as prenatal care in accordance with the information delivery needs of the Low German-speaking Mexican Mennonite farmworker population. Currently, a pilot program is in progress that offers additional outreach, health education, and interpretation, among other services. The work of the KSFHP has significant implications for further research into health disparities, specialized minority populations, and culturally competent data collection methods.Cyndi Treaster is Manager of the Kansas Statewide Farmworker Health Program within the Office of Local and Rural Health at the Kansas Department of Health and Environment. Suzanne R. Hawley is Assistant Professor, Angelia M. Paschal, Assistant Professor, Craig A. Molgaard, Professor and Chair, and Theresa St. Romain, Coordinator, all within the Department of Preventive Medicine and Public Health at the University of Kansas School of Medicine-Wichita.     

同伴教育在农村孕产妇健康促进中的应用

受多种条件的制约,农村地区的孕产期保健比较落后,传统的健康教育方式在农村孕产妇健康促进中存在局限性:①专业人员健康教育的影响是有限的;②农民文化水平低,对知识的正确理解性差;③对农村孕产妇的健康作用不持久;④耗费大量的人力、物力;⑤容易流于形式.而同伴教育得到多种社会学和心理学理论支持,在艾滋病的预防、青少年物质滥用等方面都取得很好的收效.同伴教育具有文化适宜性、可接受性、经济性、科学性的优点,应用到农村孕产妇保健从理论上是可行的,需要做社区对照试验来检验.     

免费建册在流动人口孕产妇系统保健管理中的作用

目的探索在流动人口孕产妇系统保健管理中免费为其建立孕产妇保健手册(建册)的作用。方法回顾性分析上海市静安区2007-2011年流动人口孕产妇系统保健情况年度报表数据。结果 2007-2011年每年度早孕建册率和系统保健管理率分别为31.96%、28.90%;49.48%、48.70%;53.54%、47.63%;69.33%、66.84%;83.92%、83.33%。结论免费建册的举措可以吸引更多的流动人口孕妇及早建册,从而提高早孕建册率和系统保健管理率,但对降低产后拒访率作用不明显。     

‘Just doing the best we can’: health care providers’ perceptions of barriers to providing care to Marshallese patients in Arkansas

ABSTRACT

Introduction: Marshallese migrating to the United States encounter challenges in accessing health care. Previous literature has investigated Marshallese participants’ perceptions of the barriers they face in accessing health care. For this study, health care providers managing the care of Marshallese patients were interviewed to understand the providers’ perception of barriers that their Marshallese patients encounter.

Methods: A qualitative research design was utilized to explore health care providers’ perceptions of and experiences with the barriers faced by their Marshallese patients when accessing the US health care system.

Results: The primary barriers identified were: (1) economic barriers; (2) communication challenges; (3) difficulty understanding and navigating the western health care system; and (4) structural and system barriers.

Conclusion: This study provides insight on the barriers Marshallese patients face in accessing health care as well as the barriers providers face in delivering care to Marshallese patients. A better understanding of these barriers can help health care providers and educators to begin initiating improvements in the delivery of care to Marshallese patients.     

Racial and Ethnic Disparities in the Discordance Between Women's Assessment of the Timing of Their Prenatal Care Entry and the First Trimester Standard

Objective: The purpose of this study was to investigate whether the discordance between women's assessment of the adequacy of the timing of their prenatal care entry and the standard of first trimester initiation was associated with maternal race or ethnicity. Methods: A population-based surveillance system, the California Pregnancy Risk Assessment Monitoring System, provided data on a stratified random sample of 4,987 women. The women delivered live-born infants from 1994–95 in three perinatal regions. Respondents completed an in-hospital, self-administered questionnaire. Weighted data were analyzed with multiple logistic regression. Results: Twenty-two percent of the women in the sample initiated prenatal care after the first trimester of pregnancy (n = 1,097). Among the women with untimely care, 57% (n = 591) were satisfied with the time of care initiation. Discordance between the women's perception of the adequacy of the time of care initiation and the public health standard of first trimester initiation was associated with maternal ethnicity. After controlling for potential confounders, Mexican-born women with untimely care were more likely to report being satisfied with the time of initiation than were white non-Latina women with untimely care (OR = 4.03, CI = 2.46, 6.59). Conclusions: The design of public health interventions to increase the timeliness of prenatal care initiation will require a greater understanding of pregnant women's own perceptions of their needs for prenatal care, and the differences in perceptions across ethnic groups.     

中国五城市流动育龄妇女孕产期保健影响因素研究

目的 了解流动育龄妇女孕产期保健现状及影响因素,为改善其孕产期保健质量提供依据。方法 利用2005年北京、南京、厦门、深圳和重庆5个城市流动人口生殖健康抽样调查数据,描述分析流动育龄妇女孕产期保健分布情况,用logistic回归分析流动育龄妇女孕产期保健影响因素。结果 5399份有效调查问卷中有4037来自经历妊娠的流动育龄妇女,其中参加过和未参加孕产期保健者分别占75.3%(3041/4037)和24.7%(996/4037)。初次产前检查时间与其受教育程度有关(P<0.05)。孕产期保健多因素logistic回归分析显示,孕产期保健在调查地区间存在差异(P<0.05),<30岁和30～39岁组参加孕产期保健的比例别是≥40岁组的4.09倍(95%Cl:3.11～5.39)和1.98倍(95%Cl:1.61～2.43);高中及以上、初中文化程度的流动育龄妇女参加孕产期保健的比例分别是小学及以下者的5.47倍(95%CI:3.85～7.77)和2.86倍(95%Cl:2.42～3.39);已婚流动育龄妇女参加孕产期保健比例是未婚流动妇女的2.36倍(95%Cl:1.07～5.22);生育1胎和2胎者均比生育≥3胎的流动育龄妇女更可能参加孕产期保健,其OR值分别是3.36(95%Cl:2.33～4.84)和1.61(95%Cl:1.12～2.30);有婚育证明者参加孕产期保健比例是无婚育证明者的1.44倍(95%Cl:1.21～1.71)。结论 教育程度高、已婚、生育胎数少及有婚育证明对流动育龄妇女的孕产期保健具有保护作用。通过改善孕产期保健影响因素,提高外来流动人口孕产期保健服务的利用水平,有助于预防和降低不良生殖健康结局的发生风险。     

Encouraging use of prenatal care through conditional cash transfers: Evidence from JUNTOS in Peru

We use a difference‐in‐differences strategy to estimate the effects of JUNTOS, a conditional cash transfer program targeted to poor rural households in Peru, on use of prenatal care. Using data from the Peruvian Demographic and Health Surveys over the period 2000–2011, we find that JUNTOS increased prenatal care utilization among program‐eligible women. Even more, we find positive effects of JUNTOS on the probability of receiving prenatal care delivered by a skilled professional, including specific medical checkups during the prenatal visits, and a negative effect on the probability of experiencing obstetric emergencies during labor and childbirth.     

Disparities in primary care for vulnerable children: the influence of multiple risk factors

OBJECTIVES: To analyze vulnerability as a profile of multiple risk factors for poor pediatric care based on race/ethnicity, poverty status, parent education, insurance, and language. Profiles are used to examine disparities in child/adolescent health status and primary care experience. DATA SOURCES: Cross-sectional data on 19,485 children/adolescents 0-19 years of age from the 2001 California Health Interview Survey. STUDY DESIGN: Multiple logistic regression models are used to examine risk profiles in relation to health status and three aspects of primary care: access (physician and dental visit; access surety), continuity (regular source of care), and comprehensiveness (i.e., health promotion counseling). PRINCIPAL FINDINGS: About 43 percent of (or 4.4 million) children in California have two or more risk factors (RF). Controlling for age and gender, more RFs is associated with poorer health status (i.e. percent reporting "excellent/very good" health: no RFs=81 percent, 1=71 percent, 2=57 percent, 3=45 percent, 4=35 percent, 5=28 percent, all p<.001). Controlling for health status, higher risk profiles is associated with poorer primary care access and continuity, but greater comprehensiveness of care. For example, higher risk profile children are less likely to have a regular source of care: one RF (prevalence ratio [PR]=0.92, confidence interval [CI]: 0.86-0.98), two (PR=0.77, CI: 0.69-0.84), three (PR=0.55, CI: 0.46-0.65), and four or more (PR=0.31, CI: 0.22-0.44), all p<.001. CONCLUSIONS: This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status, access to, and continuity of primary care. Having gained access, however, adolescents with higher risk profiles are more likely to receive health promotion counseling. Higher profiles appear to be associated with greater barriers to accessing primary care for children in "fair or poor" health, suggesting that vulnerable children who have the greatest health care needs also have the greatest difficulty obtaining primary care.     

Impact of recent welfare and immigration reforms on use of Medicaid for prenatal care by immigrants in California

This study investigates the impact of the recent welfare and immigration changes on the use of Medicaid by low-income pregnant immigrant women in California. The study presents findings from interviews with government officials, safety-net prenatal care providers, and immigrant advocates who serve low-income pregnant Asian and Latina immigrants at the national, state, or local levels. These informants spoke of policy actions that affect immigrants' abilities to use Medicaid for coverage of prenatal care. These actions include (1) the sharing of information between the California Department of Health Services and the federal Immigration and Naturalization Service, (2) the slow and confusing implementation of the reforms, and (3) the intimidating Medicaid eligibility process. The findings demonstrate how the policies changed the immigrant women's relationship with safety-net prenatal care providers, and sparked intense actions on the part of their advocates to sustain the women's access to perinatal care.     

An examination of sociocultural factors associated with health and health care seeking among latina immigrants

The purpose of this study was to examine the sociocultural factors associated with health maintenance and health care seeking among Latina immigrants. Data were collected from eight focus groups with 54 Latina immigrants between the ages of 19 and 62 (M=29.3±9.34). The PEN-3 model provided the framework for the study. Most of the participants came from Mexico; 46% had not completed high school; 85.2% had been in the United States for less than 7 years, and 73.6% reported not having health insurance coverage. Participants identified both positive and negative perceptions, enablers, and nurturers associated with health maintenance and health care seeking. Participants acknowledged the importance of physical, mental, and spiritual health and what they should do to be healthy. Despite such knowledge, they tended to engage in unhealthy behaviors due to a variety of nonstructural barriers such as lack of time, “tradition,” and procrastination. They tended to use alternative/complementary medicine first, and then seek medical help if these practices are not effective. Many women believe that they do not have control over their own health attributing this lack of control to the “system.” Participants also mentioned structural barriers to seeking health care such as lack of transportation, lack of proper documentation, lack of health insurance, language barriers, long waiting time at the clinics, and lack of knowledge on where to go for affordable care. Our study suggests that there are important structural and nonstructural barriers that hinder health maintenance and care seeking. The findings also lend support to the PEN-3 model, and suggest that positive perceptions, enablers, and nurturers associated with health maintenance and health care seeking, if properly reinforced, can counterbalance negative perceptions, enablers and nurturers in this population.     

Mexican women in California: differentials in maternal morbidity between foreign and US-born populations

In the US, the majority of deaths and serious complications of pregnancy occur during childbirth and are largely preventable. We conducted a population-based study to assess disparities in maternal health between Mexican-born and Mexican-American women residing in California and to evaluate the extent to which immigrants have better outcomes. Mothers in these two populations deliver 40% of infants in the state. We compared maternal mortality ratios and maternal morbidities during labour and delivery in the two populations using linked 1996-98 hospital discharge and birth certificate data files. For maternal morbidities, we calculated frequencies and observed and adjusted odds (OR) ratios using pre-existing maternal health, sociodemographic characteristics and quality of health care as covariates. Approximately 19% of Mexican-born women suffered a maternal disorder compared with 21% of Mexican-American women (Observed OR = 0.89, [95% CI 0.88, 0.90]). Despite their lower education and relative poverty, Mexican-born women still experienced a lower odds of any maternal morbidity than Mexican-American women, after adjusting for covariates (OR = 0.92, [95% CI 0.90, 0.93]). These findings suggest a paradox of more favourable outcomes among Mexican immigrants similar to that found with birth outcomes. Nevertheless, the positive aggregate outcome of Mexican-born women did not extend to maternal mortality, nor to certain conditions associated with suboptimal intrapartum obstetric care.