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This is to certify that the
thesis entitled
Prenatal Care Utilization By Pregnant

Adolescents In Ottawa, Allegan and
Kent Counties

presented by

Sonia Desiree Van Eyl Taylor

has been accepted towards fulfillment
of the requirements for

 

 

M.S. degree in College of Nursing

27sz. JW PhD/6M. 9

Major professor

Date $9M {SQ/973

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

 

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MSU Is An Affirmative Action/Equal Opportunity Institution
omens-m

PRENATAL CARE UTILIZATION BY PREGNANT ADOLESCENTS IN OTTAWA,
ALLEGAN AND KENT COUNTIES

By
Sonia Desiree Van Eyl Taylor

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1993

ABSTRACT
PRENATAL CARE UTILIZATION BY PREGNANT ADOLESCENTS IN OTTAWA,
ALLEGAN AND KENT COUNTIES
By
Sonia Desiree Van Eyl Taylor

The purpose of this descriptive study was to research the adequacy of prenatal care
adolescents in a tri-county area of Michigan received in 1990. The sample included 1583
vital statistics records for births to adolescents 19 years of age and younger, who delivered
in Ottawa, Allegan, and Kent Counties in Michigan in 1990. The Adapted Health Belief
Model was used to conceptualize and guide the investigation of the variables. Findings
revealed that adequacy of prenatal care received by adolescents less than age 15 varied.
Younger adolescents received adequate prenatal care 22% of the time and intermediate
prenatal care 55% of the time. Nineteen percent of younger adolescents received
inadequate prenatal care. Older adolescents received adequate prenatal care 47% of the
time. Thirty-eight percent of the older adolescents received intermediate prenatal care.
Inadequate prenatal care was received by 13% of the older adolescents. The remaining
percentage of the sample had received either an unknown amount of prenatal care or no
prenatal care at all. The results of this study seem to indicate a need to improve the
adequacy of prenatal care that adolescents receive in this tri-county area, especially for
younger adolescents. Possible methods for improving prenatal care include focusing on
educating the communities as to health care issues, especially the importance of prenatal
care, and encouraging health care professionals to work as the pregnant adolescent's
advocate. Future research suggests further evaluation of the demographics of the pregnant
adolescent female, and the possible barriers that the adolescent experiences when she does

seek out prenatal care.

Copyright by
SONIA DESIREE VAN EYL TAYLOR

1993

Dedicated to

my family

Without them, I would not be who I am today

ACKNOWLEDGEMENTS

There were many people who helped make this thesis possible. I want to
especially thank my committee: Millie Omar for chairing the thesis committee; Rachel
Schiffman, for co-chairing the committee with Millie; Jackie Wright for her timely
encouragements; and Georgia Padonu who gave me that extra word of support when I
was tempted to quit.

In the formation of the paper: Kathy Humphrys of the Michigan Department of
Public Health supplied me with the statistics to make this thesis possible; Randy Meyer
and Paul Gust, who gave me access to computers close to home; Andrew Santangelo
spent many hours typing the final drafts and creating charts and graphs with me; and his
wife, Lisa, who let me stay at their home late into the evening, disrupting their family
routine.

Thank you, dad, who not only made me believe in myself to continue my education,
but went through countless drafts of the thesis over the past two years to help complete
this thesis.

Finally, many thanks are owed to our friends and family who kept my family fed and

cared for while I completed this part of my education.

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

 

 

cum. The Problem

CH PTER II.

W-

Introduction

 

Purpose of the Study

Statement of the Problem

 

Summary

 

Conceptual Framework

 

Introduction

 

Conceptual Definitions

Conceptual Framework

 

Initiation and Participation in Prenatal Care

Summary

 

 

Literature Review

 

Introduction

 

Initiation of Prenatal Care

 

Adequacy of Prenatal Care
Prenatal Care

 

Summary

 

Methods

 

Introduction

 

 

Design

vi

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operational Definitions 23

Sample 25

Data Collection Procedure 25

Data Analysis 25

Protecting Human Subjects 25

Assumptions and Limitations 26

Summary 27

HA V- Results 28
Introduction 28

Overview of the Sample 28

Research Questions 31

Summary 40

A V 1. Recommendations, Interpretation, and Implications 41
Introduction 41

Summary and Interpretation of Findings 41

Initiation of Prenatal Care 43

Adequacy of Prenatal Care 45

Conceptual Framework 48

Implications for Clinical Practice 53
Recommendations for Future Nursing Research 58

Summary 59

APPENDICES 61
Appendix A: Letter of Request for Data 61

Appendix B: Letter of Available Data from the MDPH .......................... 62

Appendix C: Letter of Approval from UCRIHS 53

LIST OF REFERENCES 64

 

vii

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

LIST OF TABLES

Kessner Index as Modified by the Michigan Department of Public
Health

 

Age of the Pregnant Adolescent Population in Ottawa, Allegan, and

 

Kent Counties, Michigan in 1990

Month of Initiation of Prenatal Care by 12-14 Year Old Adolescents in
Ottawa, Allegan and Kent Counties, Michigan in 1990

 

Month of Initiation of Prenatal Care by 15-19 Year Old Adolescents in
Ottawa, Allegan and Kent Counties, Michigan in 1990

 

Percentage of Prenatal Care of 12-14 Year Old Adolescents in Ottawa,

 

Allegan, and Kent Counties, Michigan in 1990

Percentage of Prenatal Care of 15-19 Year Old Adolescents in
Ottawa, Allegan, and Kent Counties, Michigan in 1990

 

viii

3O
35
35
59

39

Figure 1.
Figure 2.

Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.

Figure 9.

LIST OF FIGURES

The Adapted Health Belief Model

Percent of adolescent pregnant females by age of pregnancy in
Ottawa, Allegan and Kent Counties, Michigan in 1990

 

Frequency of adolescent pregnant females by age of pregnancy in
Ottawa, Allegan and Kent Counties, Michigan in 1990

 

Adequacy of prenatal care received by adolescents ages 12—14 in
Ottawa, Allegan and Kent Counties, Michigan in 1990

 

Adequacy of prenatal care received by adolescents ages 15-19 in

 

Ottawa, Allegan and Kent Counties, Michigan in 1990

Adequacy of prenatal care received by adolescents ages 15-19 in

combined Ottawa, Allegan and Kent Counties, Michigan in 1990 ..........

Month of initiation of prenatal care by 12-14 year old adolescents in
Ottawa, Allegan, and Kent Counties, Michigan in 1990

 

Month of initiation of prenatal care by 15-19 year old adolescents in

 

Ottawa, Allegan, and Kent Counties, Michigan in 1990

Adapted Health Belief Model-Revised

 

11
30
30
31
32
33 ’
36

37
49

CHAPTER I
The Problem
Intrgdggg'gn

Each year over one million American women younger than 20 years of age become
pregnant. Of the approximately 3.7 million births to women in the United States each
year, 15% are infants born to mothers less than 20 years of age (T umbull, 1991).
Adolescents between ages 15-17 years had a pregnancy rate of 71.1 per 1,000 females in
1985 (U .8. Public Health Service [USPHS], 1989). In 1988, 15-19 year old females had
a birth rate of 53.6 per 1000 adolescents with a birth rate for 10-14 year olds of 1.3 per
1000 adolescents (U .8. Bureau of Census, 1991).

Adolescents who do decide to maintain their pregnancies have a higher incidence
of complications when compared to the adult female population. Complications are
greater, as the age of the pregnant adolescent decreases (Hetchman, 1989). It is thought
that one of the reasons for the higher incidence of complications among pregnant
adolescents is that they receive less adequate prenatal care than their older counterparts
(Khwaja, Hisham, Al-Suleiman, & El-Zibdeh, 1986; Savana-Ventura & Grech, 1990).
This study investigated adequacy of prenatal care among the adolescent population by
age in a tri-county area in Michigan.

When pregnancy occurs in adolescence, there is an increased risk for maternal and
neonatal morbidity and mortality (Gabbe, Niebyl, & Simpson, 1986). The increased risk
to the fetus includes poor physical development and growth. Complications for the
mother include anemias, pre—eclampsia, and cephalopelvic disproportion. Other risks for
the adolescent include: anxiety, depression, and hostility (Hetchman, 1989). There are
multiple reasons for poor pregnancy outcomes for adolescents. Many of these problems
can be addressed in prenatal care.

A major problem for many adolescent females is the lack of sufficient prenatal

care or total absence of prenatal care (Gabbe et al., 1986). Prenatal care has been cited as

1

2
a major contributing factor in the improved pregnancy outcomes for adult women

(Savana-Ventura & Grech, 1990). Nationally, of all live births in 1987, 76% of all
mothers had received prenatal care in the first trimester (U SPHS, 1989). However, only
53% of pregnant teens received prenatal care in their first trimester, compared to 79% of
all 20-39 year old (U SPHS, 1989). The purpose of this study was to describe the
adequacy of prenatal care received by pregnant adolescents by age of the pregnant
adolescent and by county where the infant was delivered.

According to a secondary analysis of data from the National Natality Survey
(Singh, Torres, & Forrest, 1985), almost one tenth of all pregnant adolescent females, age
19 and under, delayed initiation of prenatal care until the third trimester of pregnancy or
received no prenatal care at all. Of all pregnant adolescents, 50% had no care during the
first trimester, 10% had no care during the first or second trimester, and 2.4% had no
prenatal care at all (Van Winter & Simmons, 1990). The pregnant adolescent population
needs to be included as participating members of prenatal care, equivalent to the adult
population. Mth the health care community participating actively in these goals, it may
be possible to decrease maternal and fetal complications (Neeson, Patterson, Mercer, &
May, 1983; Scholl, Miller, Salmon, Cofsky, & Shearer, 1987).

Reviewing maternal mortality (Atrash, Konnin, Lawson, Franks, & Smith, 1990)
from 1979-1986, it was found that females less than age 15 had a maternal mortality rate
of 10 deaths per 100,000 pregnancies. This rate steadily decreased to a low maternal
mortality rate of 5 per 100,000 when women were between the ages of 24-29, however,
the rate also continued to rise sharply after the age of 35 to 20 deaths per 100,000 live
births (Atrash et al., 1990).

Adolescent females under the age of 16 have an increased rate of death during or
immediately after pregnancy that is five times greater than women age 20 and over
(Hetchman, 1989). There is a higher incidence of life-threatening conditions such as

pre-eclampsia, pregnancy induced hypertension, abruptio placenta, cephalopelvic

3
disproportion and prolonged labor among the teen-age population. This often results in

increased invasive procedures such as caesarean deliveries and forceps deliveries
(Khwaja et al., 1986).

Infants born to adolescent females are two to three times more likely to be of low
birthweight than the infants born to mothers age 25-29 years; they are also twice as likely
to die before one year of age (U SPHS, 1989). The higher than average infant mortality
rate for adolescents is not due to age alone. Other risk factors are associated with being a
teen-age mother. Adolescent mothers are more likely than older mothers to be poor and
unmarried. They are also shorter in height, weigh less, are less educated, and most
importantly, less likely to receive adequate prenatal care (U SPHS, 1989).

This delay or lack of prenatal care may be due to several factors or conditions. The
factors include denial, fear that the client-provider confidentiality will be breached, fear
of discovery of the pregnancy, and no or limited access to adequate prenatal care (Van
“Winter & Simmons, 1990). Other conditions cited in the delay or lack of prenatal care
are lower socioeconomic class, and drug and alcohol use (Gabbe et al., 1986).

In the 1970’s, the school of thought in relationship to pregnancy complications
during adolescence was related to adolescent females not being developmentally mature.
However, more recent research (Scholl et al., 1987) indicates that many of the
complications relate to the lack of adequate prenatal care. Adequacy of prenatal care in
adolescents appears to be difficult to investigate. It is the expectation that this research
can be instrumental in evaluating the current prenatal utilization behaviors of the
adolescent population in a tri-county area in Michigan.

W

The components of prenatal care focus on the mother and the infant. The broad
objectives of prenatal care are to promote the health and well-being of the pregnant
woman, the fetus, the infant, and the family up to one year after the infant’s birth

(USPHS, 1989). Three components are included in these objectives: (a) evaluation of

4
early and continuing risks of the adolescent, (b) health promotion, and (c) medical and

psychosocial interventions and follow-up (U SPHS, 1989).

Overall Objectives of prenatal care in the past have focused on the prevention of
pre-eclampsia and other maternal conditions of the fetus and newborn. Currently, the
prenatal goals are being developed to incorporate health promotion and well being of the
family (USPHS, 1989).

The goal of the National Institute of Health and Human Services is to reduce
complications of pregnancy in adolescents to no more than 15 per 100 deliveries from
the current rate of 22 hospitalizations per 100 deliveries in 1987 (USPHS, 19913). Many
of these complications that occur during pregnancy are not necessarily preventable, but
controllable to a certain extent.

Research has addressed prenatal care in programs utilizing a select population,-such
as inner city residents, minorities, or lower socioeconomic populations (Hardy, King, &
Repke, 1989; Scholl, Hediger, Khoo, Healey, & Rawson, 1991). Some studies report on
the use of technology and diagnostics in the delivery of prenatal care to evaluate the
quality of prenatal care and the subsequent outcomes (Hardy et al., 1989; Leppert &
Namerow, 1985; Petitti, Hiatt, Chin, & Croughan-Minihane, 1991; Quick, Greenlick, &
Roghmann, 1981). The populations in these programs are small in number and tend to
be adult women who have been chosen from a select population. There is minimal
current research focusing on the females who have no access to special programs.
Adolescents, when they are studied, seem to have poorer access to prenatal care than the
adult population.

The purpose of this study was to describe the initiation of prenatal care and the
number of prenatal visits as a measure of adequacy of prenatal care utilization by
pregnant adolescents by age in a tri-county area. The adolescent population was divided
into two groups. This includes pregnant females 14 years of age and younger, and

pregnant females, 15-19 years of age. Physically, there are differences between the two

5
groups. Most adolescent females 15 years and older have gone through menarche and

are more apt to be able to conceive with sexual activity (Connell, 1992; Treloar,
Boynton, Behn, & Brown, 1970). Adolescents less than age 15 have increased
complications. Some researchers have theorized that it is because of their lack of
physical development (Connell, 1992).

The results of this study may better guide and direct health care providers who deal
with the pregnancies of adolescents in those counties. Onset of prenatal care and the
consistency of visits after initiation can guide health care providers in their educational
efforts in the community.

W

The three counties that were the focus of the study were Kent, Ottawa, and Allegan
counties in southwestern Michigan. These counties have the fastest growing population
in the state. Kent county has the second largest metropolitan area with a population of
484,600 people, a strong industrial base, income per capita of $16,908.00,
unemployment rate of 5.4%, and seven health care facilities available to the community
(Klohs, 1990). Ottawa county has an income per capita of $16,190.00, a 5%
unemployment rate, equal industrial and commercial income base, and three smaller
hospitals available for health care (Rizzio, 1990b). Allegan county is one of the poorer
counties in southwest Michigan. It is financially dependent primarily on the harvest of
fruit crops during spring, summer and fall. There is some indusu'y and commercial
income base also. The unemployment rate is 5.0%, with an income per capita of
$13,861.00 (Rizzio, 1990a). In order to better understand what the tendencies of
adolescents in initiation of prenatal care, this study will attempt to answer the following
research questions:

1a) What percentage of pregnant adolescents in the sample receive adequate

prenatal care for each county?

6
1b) What percentage of pregnant adolescents receive intermediate prenatal care for

each county?

lc) What percentage of pregnant adolescents receive inadequate prenatal care for
each county?

2) What percentage of pregnant adolescents in each of these three counties
initiated prenatal care in each of the nine months of pregnancy?

3) What is the mean number of prenatal visits of the pregnant adolescents for each
of the counties?

To answer these questions, a retrospective secondary analysis was conducted, using
vital statistics data for 1990 obtained from the Michigan Department of Public Health
(MDPH). The Adapted Health Belief Model was used as a framework for this study.
Data was described using the maternal age at delivery, month of onset of prenatal care
and total number of prenatal visits.

Summary

The first chapter contains an overview, the description of purpose and the
importance of this investigation. In Chapter II, the conceptual framework which guided
this investigation is presented. Chapter III contains a review of pertinent literature. A
description of the methodology used to carry out this investigation is presented in
Chapter IV. The analysis of the data is found in Chapter V. Chapter VI contains the

summary, interpretation, conclusion and nursing implications of this investigation.

CHAPTER II
Conceptual Framework
Introduction
This chapter includes an introduction to the conceptual framework used in this

study. Selected concepts from the Health Belief Model were used to guide this research
study and the conceptual definitions under study are included in this chapter. The Health
Belief Model was developed in the early 1950’s by Rosenstock, Hochman and Kegeles
(Becker & Marshall, 1974) with two different foci in their framework in reference to
people’s health seeking behavior. The first aspect of the framework explored people who
were illness free and the different factors which influenced them to take actions to avoid
illness. The second aspect of the framework explored people who failed to take such
protective actions (Becker & Marshall, 1974). The Health Belief Model was adapted
(Adapted Health Belief Model) and utilized in this study with the theory that modifying
factors influence individual perceptions. The modifying factors and the individual
perceptions subsequently impact the likelihood of action. The likelihood of action
determines the adequacy of prenatal care (Edelman & Mandle, 1990).

Adequacy of prenatal care for this study was based on Kessner's Index (Table 1)
modified by the Michigan Department of Public Health (MDPH). The Kessner Index
groups prenatal care into three categories. Level I and Level II are the same in the
Kessner and Modified Kessner Index. Level III in the Kessner Index includes no care
and unknown amount of prenatal care categorizations in this grouping. The Modified
Kessner Index includes unknown prenatal care categorization as a separate grouping.

it al fi i '
ua f tal

Prenatal care and its adequacy are based on two major factors. It is based on the
time of the first prenatal visit during the pregnancy and the total number of prenatal

visits. Prenatal care has not been well defined conceptually in recent research literature.

7

 

 

 

Prenatal Care Index Month care began Gestation # of visits
(weeks at delivery)
Level I Within first three months 13 or less >1
Adequate
14- 17 >2
18-21 >3
22-25 >4
26-29 >5
30-31 >6
32-33 >7
34-35 >8
Seventh month or later or >36 >9
no care
Level II All combinations other than specified for Levels I and 111
Intermediate
Level 111 14-21 0
Inadequate
22-29 <1
30-31 <2
32-33 <3
>34 <4
Unknown Amount of Prenatal
Care

 

Note. From "Prenatal care and pregnancy outcome in an HMO and general population: A multivariate

cohort analysis" by 1. Quick, M. Greenlick & K. Roghmann, 1981, mm, 11

(4). p. 381-390.

9
One study in the literature by Scholl et a1. (1987) attempted to define prenatal care by

describing what prenatal care should include. In this prospective study of 757 women,
the author defined prenatal care as adequate, intermediate, and inadequate. Adequate
prenatal care was defined with the patient entering care in the first trimester and
receiving the requisite number of visits for the gestational period. Inadequate care was
defined as care that began in the last trimester or entry was in the the second trimester
with fewer visits as stipulated by the researcher’s guidelines. Intermediate care was
considered all other combinations of care with initiation in the first or second trimester.
It was found that those with adequate prenatal care had improved pregnancy outcomes.

Others (Gorsky & Colby, 1989) reviewed New Hampshire birth certificates to
evaluate the cost effectiveness of prenatal care. The researchers used the adequate,
intermediate, and inadequate prenatal care definitions cited in Scholl et a1. (1987) to
show that prenatal care reduced costs in medical care. This was done through decreasing .
preterm deliveries and through early detection of potentially complicating factors.

Alexander and Comely (1987) applied the adequacy of prenatal care criteria and its
relationship to pregnancy outcome. Their study focused on all white pregnant women
seen in South and North Carolina from 1982-1987. Increased utilization of prenatal care
was associated with an increase in the mean birth weight and gestational age of the
infants.'

For the purpose of this study, adequacy of prenatal care is defined quantitatively by
the onset of prenatal care and the amount of subsequent prenatal visits (Quick et al.,
1981). The onset of prenatal care is based on the weeks gestation that care began based
on the last menstrual period. Classifications include adequate, intermediate and
inadequate prenatal care. Adequate prenatal care is the most comprehensive, with visits
beginning early in the first trimester, and subsequent visits continuing at regular interval
throughout the pregnancy (Quick et al., 1981). Inadequate prenatal care has been defined

by late entry in the last trimester and/or less than seven total visits throughout the

10
pregnancy (Quick et al., 1981). Intermediate care has been defined by the criteria that
does not encompass either of the above classifications for prenatal care (Quick et al.,
1981). However, complications occur and infants are delivered prematurely, despite
prenatal care. The prenatal health services indexes take into consideration women who
have infants delivered before term by having proportionally fewer visits.
angeptgal Framework

To guide this study, the Health Belief Model (HBM) was adapted (see Figure 1)
and was used to explain entry for prenatal care and the amount of prenatal care obtained
by the adolescent population through the concept, likelihood of action. The likelihood
of action is based on (a) perceived benefits of decreasing maternal and fetal risks, and (b)
barriers of demographic, structural and sociopsychological variables.

The adolescent’s belief of decreasing maternal and fetal risks is based on the
adolescent’s perception of her pregnancy and her susceptibility to complications. Some
adolescents may deny pregnancy, while others may not understand the ramifications of
pregnancy. For those that do understand that pregnancy is a health condition, they may
believe that because they are young and in good health, complications are not probable
(Joyce, Diffenbacher, Green, & Sorokin, 1984).. The end result is the likelihood of action
impacting the amount of prenatal care that the adolescent subsequently receives.

The pregnant adolescent's barriers to obtaining prenatal care could be either
perceived or real. Real barriers to obtaining prenatal care include the lack of insurance
and/or money, difficulty accessing prenatal care due to lack of transportation or difficulty
finding a physician to accept her as a patient (Joyce et al., 1984). The end result often is
late entry into prenatal care, or entry into prenatal care and withdrawal before delivery.
Perceived barriers include fear, knowledge deficit of pregnancy and the importance of
prenatal care, depression or denial, and actual perception of how one is treated in the
healthcare arena (Joyce etal., 1984). Once the adolescent female is pregnant, real and

perceived barriers guide the adolescent into her decision making. The end result is the

Individual
Perceptions

 

Maternal
Perceptions

 

11

Modifying Factors

Likelihood of Action

 

 

 

 

 

 

Demographic Variables

Sociopsychologic
Variables

Structural Variables

1

Benefits of
decreasing
maternal/fetal risks

 

 

Barriers of
Demographic,
Structural and

Sociopsychologic
Variables

 

 

 

13mm. The Adapted Health Belief Model.

1

 

 

Initiation of Care
4.
Continuity of
Visits
Adequacy of
Prenatal Care

 

 

_<zteN . From W" (p. 7) by M. Becker
and C. Marshall, 1974, Thorofare, N.J.: Charles B. Slack.

 

 

12
likelihood of action of the pregnant adolescent. More specifically, the perceived and real

barriers that influence the likelihood of action are described as modifying factors, which
also impact the adolescent in the seeking of prenatal care. These include demographic
variables of age, sociopsychologic variables, such as prior pregnancies and their
outcomes, and structural variables, such as accessibility to prenatal care in her
community.

In summary, to assess the person’s likelihood of taking preventative actions, the
healthcare provider compares the picture of susceptibility of the adolescent with (a)
perceived internal and external barriers, (b) individual perceptions of benefits. and (c)
modifying factors. This can subsequently help explain the initiation and continuity of
care among the general adolescent population. The action of the pregnant adolescent is
either to seek out or to hold off the seeking of prenatal health care, which was the focus
of this study.

The Health Belief Model does not specify which type of interventions most likely
to irnprove an individual’s likelihood of taking preventive health action. The
development of the most appropriate professional interventions for a particular client
must be negotiated between the client and health care provider (Edelman & Mandle,
1990).

For the purpose of this study, the final outcome (likelihood of action) within the
Health Belief Model was the adequacy of prenatal care which includes the initiation and
continuity of care. This study will not address baniers or benefits related to the
likelihood of action. Subsequent research is needed to investigate the negotiation of
appropriate interventions between the pregnant adolescent and the healthcare provider to

better improve the likelihood of action of the adolescent.

' i ' n i i i n ° n

Initiation and participation in prenatal care is a complex activity for the adolescent.
Use of the Health Belief Model provided an organized framework to explain the factors
involved in the decision making of the pregnant adolescent in the pursuit of prenatal
care (see Figure 1). The factors include barriers and benefits that the adolescent believes
are relevant at the time, a part of the concept of likelihood of action within the HBM.
Likelihood of action is dependent upon benefits and baniers. Although these factors are
not part of this research, they will be discussed in this chapter, for further understanding
of the concept .of likelihood of action.

m

Beliefs about the effect of preventive actions appear to be important determinants
of health-protecting behavior. It is assumed that those that initiating and participating in
prenatal care throughout pregnancy have decided that the benefits outweigh the internal
or external barriers. A healthy pregnancy and healthy outcome may be the reason behind
the initiation of care.

Of relevance to this study is initiation of action in relationship to W
prenatal pare. Prenatal care is most effective if initiated in the first trimester. The
adolescent must first overcome the barriers and view prenatal care as a benefit to her
health and to her baby’s health. Some adolescents will become aware of prenatal care
benefits without a health care provider becoming aggressive in the education of the
adolescent. However, for those adolescents who do not initiate prenatal care in the first
trimester, and continue throughout pregnancy with health care visits, the Clinical Nurse
Specialist (CNS) has an important role.
am

If an adolescent does end up with an unintended pregnancy, there may be fear of
the unknown, and uncertainty of how to inform her parents of the pregnancy. The

adolescent often continues to deny her pregnancy until it is too obvious to hide anymore.

14
and then access to the health care system begins, usually in the second trimester and after
organogenesis (Carter & McGolderick, 1988).

The barriers to obtaining preventative care can take many forms and can be
perceived or real. Cost, age, inconvenience, unpleasantness, or extent of life change
required are some possible blocks to engaging in preventative behaviors. The
adolescent, once pregnant, faces a multitude of barriers in the accessibility of prenatal
care. The lack of money in general is one of the most serious barriers to adequate
prenatal care. Other barriers include age, home life situation and lack of understanding
of pregnancy and reproduction.

lini lN r i listR l

The role of the Clinical Nurse Specialist (CNS) is multifocused, for both those
adolescents who perceive prenatal care as a benefit and seek prenatal care. as well as-
those who feel that prenatal care has too many baniers, and do not become involved in
the health care system. The CNS needs to include focusing on all aspects and concerns
of the adolescent. The pregnant adolescent has as many, if not more, needs as the adult
female, and may or may not be assertive enough to ask questions or express her needs.
This includes the biological, psychological, social and spiritual needs that may be
mentioned or not mentioned by the adolescent. It is the role of the CNS to encourage
health care participation of the pregnant adolescent especially once the adolescent has
initiated prenatal care. However, the CNS does not know what intervention is best
needed for prenatal care for adolescents in a particular area without information about
the extent of use of prenatal care by adolescents.

Shaman

Prenatal care for pregnant teenagers is an important predictor of the outcome of
pregnancy (Wells, McDiarmid, & Bayatpour, 1990). However, it is questionable if
adolescents are receiving the prenatal care recoMended by the health care community.

The Health Belief Model can possibly predict prenatal attendance in pregnant

15
adolescents (Wells et al., 1990). This research study addressed only the likelihood of

action in relationship to adequacy of prenatal care in an adolescent population.

In this chapter the conceptual definition of adequacy of prenatal care was provided.
It was conceptualized in the Health Belief Model which provided the direction for this
study. In Chapter HI a review of literature relevant to the concepts under study are

discussed.

Chapter 111
Literature Review
Intrfluctigg

This chapter reviews the recent literature regarding adequacy of prenatal care,
initiation of prenatal care and the number of prenatal care visits that pregnant women
receive. The medical aspects of pregnancy are well documented (Gabbe et al., 1986).
Pregnancy research has included preterm labor, complications of certain activities on
pregnancy outcomes, mortality, and morbidity (Field, 1990; Hetchman, 1989; Sanderson,
Placek, & Keppel, 1991). These studies primarily research the pregnant adult female and
focus on the outcome of pregnancy. In recent years, research has been focusing on the
adolescent as well as the adult pregnant female (Kurup, Vregas, Singh, & Ratnan, 1989;
Scholl et al., 1991; Stevens-Sirnon, Roghmann, & McAnarney, 1991).

ni i i n n 1

Through a survey of national natality statistics of all pregnant adolescents in the
United States, 50% have no care in the first trimester, 10% have no care during the first
or second trimester, and 2.4% have no prenatal care whatsoever (Van Winter &
Simmons, 1990). Van Winter and Simmons’ (1990) conclusions were that the delay or
the omission of care is due to a combination of fear of discovery, fear of breach of
confidentiality, financial restrictions, and poor access to medical care.

A prospective study's reported results of a select group of women in New Jersey,
found while assessing maternal weight gain, diet and infant birth weight. that the
initiation of prenatal care when compared to national statistics of prenatal care was
significantly later for adolescents than their adult counterparts (Scholl et al., 1991). Over
60% of the adolescent sample had prenatal care beginning after the first trimester and
greater than 10% had prenatal care beginning into the third trimester. Of this sample,
75% of the adolescents were Medicaid supported. One of the possible explanations for
the delay in medical care not discussed in this research is that many of these adolescents

16

17
may delay seeking prenatal care until after Medicaid has been initiated. Another

possible reason for late prenatal care is the population studied may not understand the
importance of prenatal care. There may also be difficulty in accessing available prenatal
care.

Clinic environment can hinder or aid in the seeking of prenatal care in the
adolescent. Cartoof, Klerman, and Zazueta (1991) concluded that the factors which limit
adolescents’ utilization of prenatal care include aspects of the clinic environment in
which care is provided. In the Cartoof et al. (1991) study, clinic attractiveness assessed
through surveys of 466 pregnant adolescents, was found to exert a stronger influence
than ethnicity, age, source of payment for care, or the presence of a clinic in the
neighborhood. Comfort and convenience of a prenatal clinic as well as how the
adolescent was treated by the staff and health care practitioners appeared to positively
affect early registration for prenatal care and keeping appointments (Cartoof et al., 1991).

Another study described a specific program that had a population that met specific
inclusion criteria (Buescher, Meis, Ernest, Moore, Michielutte, & Sharp, 1988). This
study had an adolescent population that was small. Another bias in this program is that
the population was selected from women who have initiation at a certain point during
their pregnancy. Subsequently, there is no comparison to the general population or
adolescents who may not have access to such programs.

W

A review of maternal mortality statistics from 1979-1986 found that during this
period, 5.5% of all women in the United States who had a live birth had inadequate
prenatal care. In addition, 15% of all women who had alive birth and subsequently died
had inadequate care (Atrash et al., 1990).

A review of national natality statistics by Young, McMahon, Bowman, and
Thompson (1989) indicated that six percent of girls less than 16 years of age and three

percent of girls 15 to 17 years of age received no prenatal care as compared to one

18
percent of their older counterparts. The perinatal outcome of adolescent mothers, 15

years of age or less continues to be poorer despite adequate prenatal care. There was no
additional research to conclude why adolescents are not accessing prenatal care as well
as their adult counterparts.

Many other researchers have applied the utilization of prenatal care and its
relationship to pregnancy outcome (Alexander & Comely, 1987; Scholl et al., 1987).
Each of the studies divided prenatal adequacy into groups depending on the onset and/or
the number of prenatal care visits received. Overall, the conclusions were that the early
onset of prenatal care and the consistency in visits throughout pregnancy improved
pregnancy outcome (Alexander & Comely, 1987; Quick et al., 1981; Scholl et al., 1987).

Tyson, Guzick, Rosenfeld, Lasky, Gant, J imminez, and Heartwell (1990) after
reviewing prenatal care and pregnancy outcomes in a selected population concluded that
pregnancy outcomes were improved only with the visits at 34-, 38-, and 42- weeks of
gestation. However, only women who were not going to give the study a “preterm
delivery bias” were included. Preterm delivery biases were those pregnant women with
medical histories of prior preterm deliveries or miscarriages, for example. Excluding
these preterm infants can justify such prenatal care conclusions. however, preterm
delivery is the primary cause of infant morbidity and mortality, and prenatal care is the
only means at this point that health care practitioners have to detect and work with
preterm delivery and optimize the situation as it arises (Gabbe et al., 1986)‘.

About half of all women who have not completed high school receive late or no
prenatal care, compared to 10% of college educated mothers. Birth outcomes are poorest
if a pregnant woman does not see a health professional until the last trimester of
pregnancy (Moore, Origel, Key, & Resnik, 1986). In 1987, 37 million Americans lacked
health insurance, and of these, more than 12 million were children under age 18

(U SPHS, 19913).

19
W

In a study by Wells et a1. (1990), the Health Belief Model was used as a predictor
for prenatal appointment keeping rates among pregnant teenagers. They combined the
HBM with a tool called the Perinatal Health Belief Scales (PHBS), which measured the
individual perceptions of the adolescent female. The study’s conclusions were that the
HBM effectively predicted prenatal appointment keeping rates among pregnant teenagers
and that the psychosocial risk factors did not appear to be related to appointment
keeping. Specifically, teenagers’ appointment keeping rates vary systematically based on
the extent of agreement or disagreement between the HBM and the PHBS (Wells et al.,
1990). The sample included 63 adolescents and used only one site. Also, the majority of
the patients were from a minority background and the health attitudes among majority
teenagers was undersampled.

Findings in Malta and Singapore are similar to those in the United States (Kurup et
al., 1989; Savana-Ventura & Grech, 1990). Kurup et al. (1989) found that in a study
involving 255 unmarried women of whom 150 were adolescents, the adolescents over
age 16 with an equivalent amount of prenatal care as the women over 19 had similar
percentages of complications related to antepartum. However, teenage mothers were
more likely to be primigravida and poor attenders of antenatal care. Between 18% and
32% of the adolescents in each of the three study groups had no antenatal care prior to
entry into labor and delivery.

Kay, Share, Jones, Smith, Garcia, and Yeo (1991) compared a community based
prenatal care program with comparable adolescents in a traditional prenatal care program
at a university medical center. Despite the difference in the process of care that these
adolescents received, the outcomes were similar. University run clinics tend to deal
more with the undeserved and the population with a potential for higher risk during
pregnancy and can skew the results by making it appear that the undeserved have equal

access to health care. Extra precautions. such as laboratory tests or educational programs

20
may be included as regular prenatal care through these institutions, and detect earlier

physical or educational problems, before these problems affect the fetus or the mother.
These precautions may also bias the results of this study.

Stevens-Simon et al. (1991) concluded in their study about early vaginal bleeding,
late prenatal care and misdating in adolescent pregnancy, that a history of vaginal
bleeding in the first trimester is unclear but may reflect age—related differences in the
hormonal milieu early in pregnancy. During adolescence the menstrual pattern is less
uniform than it is later in life (Treloar et al., 1970). Therefore, adolescents may mistake
early first-trimester bleeding for menstrual bleeding more often than do adults, thus
delaying recognition of pregnancy and their entry into prenatal (Stevens-Simon et al.,
1991). The sample in this study was described as biased, however, the actual number of
the subjects was not given. The population consisted of primarily black, prirniparous,
and unmarried poor women. No consideration was taken as to the possibility of poorer
health among this population, nor the lack of awareness of their bodily functions.

A study in New York, however, found that a comprehensive program, despite the
late entry of many of the adolescents into prenatal care, affected costs and averted
complications (Leppert & Namerow, 1985). Of the 395 women enrolled into the
program, 10.3 % of the entire study group ended their pregnancies with infants weighing
2500 grams or less. There were 51 women during the period of this study that presented
at delivery with two or fewer visits during the pregnancy. Thirty five percent of these
women who had two or fewer prenatal care visits had babies that weighed 2500 grams or
less. The conclusions to this study (Leppert & Namerow, 1985) were that the additional
costs of providing comprehensive care are more than recovered with the costs saved by
reducing low birth weight babies. In addition, despite late entry into prenatal care, there
were maternal and fetal benefits. This study did not control for such variables as
personality characteristics of the teenagers, the social support systems available to them,

or other environmental circumstances. There was also no discussion as to racial, age or

21
socioeconomic status of any of the adolescents.

The available research consisted primarily of studies focusing on subjects that were
being cared for in a specific healthcare facility. There is very little literature dealing with
the general population. Most studies consist of populations of inner city poor women.
Sample biases include the type of health insurance, place of residence, societal situations
and prenatal history to name a few. However, those studies that were available, showed
that comprehensive care, even if initiated in the second trimester, is beneficial, albeit not
as beneficial as initiating prenatal care in the first trimester (Merkatz, Thompson,
Mullen, & Goldenberg, 1990; Quick et al., 1981; Sokol, Woolf, Rosen, & Wemgarden,
1980). Future research needs to focus more on the pregnant adolescent female and her
health care seeking patterns in both a selected and experimental setting.

itinerant

Pregnancy is a normal reproductive function. It is not, however, a venture without
risk or complication. Through the advances of nursing and medicine, it is not as great a
risk as it once was. Prenatal care has increased the early detection of many of the
problems of pregnancy, decreasing many of the detrimental effects of pregnancy related
complications.

The concept of prenatal care is known to the general public. There is no one
specific reason that prenatal care, when available, is not accessed. There is a trend for
increased complications in those females who choose not to enter the health care system
for prenatal health care. This is especially evident among adolescents who tend to have
less prenatal care and more complications. There is very little current research as to
when adolescents initiate prenatal care and once prenatal care is initiated, to what extent
adolescents continue with prenatal care.

The available research consisted primarily of studies focusing on subjects that were
being cared for in a specific healthcare facility. There is very little literature dealing with

the general population. Most studies consist of populations of inner city poor women.

22
Sample biases include the type of health insurance, place of residence, societal
situations and prenatal history to name a few. However, those studies that were
available, showed that comprehensive care even if it is initiated in the second trimester,
is beneficial, even though it is not as beneficial as initiating prenatal care in the first
trimester (Merkatz et al., 1990; Quick et al., 1981; Sokol et al., 1980). Future research
needs to focus more on the pregnant adolescent female and her health care seeking

patterns in both a selected and experimental setting.

CHAPTER IV
Methods
In (1 i n

This chapter addresses the research methods of the study. The steps, procedures
and strategies for gathering and analyzing the data are described. Operational definitions
used as a basis for this research include initiation of prenatal care, number of visits, and
adequacy of prenatal care. The sample that was studied as well as the data collection
procedure are also discussed.

Design

In this study, a description of the relationships between age of adolescents and
adequacy of prenatal care in a tri-county area through a secondary analysis of vital
statistics information was done.

i n l fini i

The Michigan Department of Public Health (MDPH) codes adequacy of prenatal
care into three categories based upon the month prenatal care began. length of gestation
and the number of visits currently referred to as the Modified Kessner Index (Kessner,
Singer, Kalk, & Schlesinger, 1973; Quick et al., 1981). Initially, the index was
developed to study infant outcomes. However, agencies have found it applicable in
categorizing prenatal care. The MDPH is one such agency.
W

W. This is the trimester that the adolescent first presents to
the health care provider for prenatal care as documented on the certificate of live birth, in
the section titled, "month of pregnancy prenatal care began."

Nnmmr 9f pgenatal page visits. This is the total number of visits to the health care
provider that the adolescent attended throughout her pregnancy, as documented on the

certificate of live birth, in the section titled, "total prenatal visits."

23

24

W. This consists of three levels. The Kessner Prenatal
Care Index includes taking into consideration the month prenatal care began and the
number of prenatal visits made by the pregnant female during the course of her
pregnancy as well as gestational age in weeks at delivery. Adequacy is operationally
defined by the MDPH modified Kessner Index which is calculated as follows:

1. W is defined as care which was begun within the first
trimester and which includes an average of at least one or two additional prenatal visits
per month of gestation depending on the length of gestation. The total number of visits
would total between 10 and 14 visits for a gestation greater than 37 weeks (Michigan
Department of Public Health, 1990).

2. W is defined as care which was begun either during the
first or second trimester of the pregnancy but with correspondingly fewer visits
occurring than would be appropriate for the length of gestation at the time of delivery
(Michigan Department of Public Health, 1990).

3. W is defined as no care being received or care begun
during the first trimester but with fewer than five total visits made throughout the course
of pregnancy (Michigan Department of Public Health, 1990).

4. Unknown is defined as the amount of prenatal care is not known (Michigan
Department of Public Health, 1990).

Adm For the purpose of this study adolescence is defined as a female less
than the age of 20. There is no lower limit to the age group since adolescence is
dependent on the adolescent proceeding developmentally through puberty, rather than at
a specific age. For the purpose of this study, adolescents are divided into two categories.
The first category consists of adolescents ages 14 years and younger. The second
category consists of adolescents ages 15 years and older. These age divisions are based

on the divisions that the MDPH utilized.

25

am le

The sample was the 1583 vital statistic records for births to adolescent females, 19
years of age and younger, in Kent, Allegan and Ottawa Counties in Michigan in 1990.
The second largest metropolitan area in Michigan is in one of these counties. There were
approximately 19,000 adolescent pregnancies in the state of Michigan in 1990; 1583
(approximately 8%) of these pregnancies were in the tri-county area of Allegan, Ottawa,
and Kent Counties.

Dat 01] i n Pr ur

Primary data were collected by the Michigan Department of Public Health from the
birth certificate data. A letter was sent to the Michigan Department of Public Health
(Appendix A), requesting access to the data related to adolescent pregnancy. Information
specifically requested was the age of each pregnant adolescent, county of birth,
gestational age of the infant, the month that prenatal care began, and the total number of
prenatal visits made. Data was provided by the Michigan Department of Public Health
(Appendix B).

W

Descriptive data from birth certificate records from 1990 were retrieved from the
computer bank at the Michigan Department of Public Health. This included:
gestational age, number of visits, onset of prenatal care, and the county of delivery. Each
of these items was categorized by two separate age groupings. Primary data analysis was
done by the MDPH in an aggregate form. The age groupings included adolescent
females ages 14 years and younger, and adolescent females ages 15 years and older.

Three questions have been posed in this study. The MDPH modified Kessner
Index was used to answer the first question. The frequency and percentage of
adolescents in each adequacy category by age and county was also calculated. using

cross tabulation. The second question relates to the total number of prenatal visits. The

26
mean number of prenatal care visits for the pregnant adolescent by age and. county was

calculated. The final question relates to the frequency and percentage for the month that
prenatal care began. A cross tabulation was done using the variables of the month
prenatal care began by age and county.

Preteeting Haman Saejgts

This study involved data that the MDPH had attained on human subjects. This
researcher had no contact with the subjects. There was no request for personal or
identifying data. Thus, there was virtually no possibility of breach of confidentially and
the rights of privacy of the pregnant adolescents were protected. Approval from
University Committee for Research Involving Human Subjects was received on March 6,
1992 (see Appendix C).

Assumptiens and Limitatiens

For the purpose of this research, the following assumptions were made:

1. Prenatal care is available to the pregnant adolescent, therefore, all pregnant
adolescents will obtain prenatal care.

2.. Pregnant adolescent females receive prenatal care that is comparable to that of
pregnant adult females, therefore, it is that the variation in pregnancy outcomes is not
due to a lesser standard of prenatal care for pregnant adolescent females.

3. The birth certificate from which the information is obtained was filled out
accurately according to state regulations by the health care provider and/or other
appropriate personnel. It is assumed that the information given is correct.

Limitations to this study are the inability to draw causal conclusions from the
results, however, these findings can be used for practical purposes and provide a
direction for future research. Other limitations identified in this study include:

1. The study is retrospective in design, therefore, the information is limited to data
that was obtained through the Michigan Department of Public Health.

2._ The sample is limited to the Counties of Kent, Ottawa, and Allegan. Therefore,

27
the results of this study may not be applicable to other counties.

3. Other contributing factors towards maternal and fetal health were not be taken
into consideration, therefore, prenatal visits may be altered based on early complications
during pregnancy, or early delivery.

Summary

This chapter reviewed the research methods of the study. The steps, procedures,
and strategies for gathering and analyzing the data have been reviewed. Operational
definitions included in this research are prenatal care, number of visits a adequacy of
prenatal care. Limitations and assumptions were also included in this chapter. The
MDPH agreed to cooperate in the data collection and analysis. Chapter V describes the

results.

CHAPTER V
Results
Introductien

In this chapter demographic data of the study and descriptive statistics relevant to
the research questions are presented. The age and race of the population are discussed.
The results of the research questions are given. Additional observations are made.

mewiew ef the Sample

The data were obtained from the 1990 birth records obtained from the Michigan
Department of Public Health (MDPH). There were a total of 1583 births reported in the
counties of Allegan, Ottawa, and Kent for adolescents ages 12 to 19 years of age. This
was 11% of the total number of births (N = 14,418) in the tri-county area. In Allegan
County, 12% (11 = 178) of all births (n = 1475) were to adolescents between ages 14 and
19 years. Ottawa County had 8% m = 245) of the total pregnant population being
between the ages of 12 and 19. Whereas in Kent County, 12% of all births (a = 9780)
were to adolescents between the ages of 12 to 19 years (Figure 2).

In the United States, one out of every 10 adolescents becomes pregnant every year
(T umbull, 1991). The tri-county area adolescent birth rate of the study is similar to the
settings that exists between the three counties. Allegan County is mostly rural (Rizzio,
19903), whereas Kent County is predominantly urban (Klohs, 1990).

As seen in Table 2, adolescents giving birth in Allegan, Ottawa and Kent Counties
ranged in age from 12 to 19 years. The mean age and standard deviation were also
similar between counties. The mean age for all adolescents giving birth in these three
counties combined was 17.8 years (T able 2). Nineteen-year old females made up 36%
(n = 577) of the adolescent population giving birth in these three counties. Slightly more
than one quarter of the adolescents who gave birth were 18 year olds (n = 443). One
third of the remaining adolescents who gave birth in the tri-county area occurred among
adolescents 17 years or younger. Adolescents 14 years or younger cOnsisted of less than

28

29
3% (a = 36) of the total adolescent population giving birth in the tri-county area (Figures
2 and 3).

Kent County had a higher number and percent of younger pregnant adolescents
than Allegan and Ottawa Counties combined. Kent County also had the only pregnant
adolescents under age 14.

Reiarfltflam

The research questions focused on varying aspects of prenatal care. Because there
were so few adolescents 14 years and younger, the results will be described dividing the
adolescents into two categories: those 14 years and younger, and those 15 years to 19

years.

Percent of
Adolescent
Pregnancy

 

16 17 18

Age of Pregnant Adolescent in Years

Emmi. Percent of adolescent pregnant females by age of pregnancy in Ottawa,

Allegan, and Kent Counties, Michigan in 1990.

 

 

 

 

 

County
Ottawa Allegan Kent All
1121 247 178 1158 1583
M b 17.80 17.79 17.69 17.77
52° 1.2 1.2 1.4 1.9
Range 14- 19 14 - 19 12 - 19 12 -19

 

2‘Total number of pregnant adolescents in the described area. bMean age of pregnant adolescents in
the described area. 6Standard deviation of the age of adolescents in the described area.

Frequency of “0°
Adolescent Pregnancy

  
       

300

All

. Allegan
1 7 1 8
Age of Pregnant Adolescent at Delivery in Years 19

Ottawa

Figam 3. Frequency of adolescent pregnant females by age of pregnancy in Ottawa,

Allegan and Kent Counties, Michigan in 1990.

31
Reseth Qpestion 1a What percentage ef ageleseents in the sample receive adequate
r n f r ch unt ?

Adolescents who were between the ages of 12 and 14 ( p = 36 ) in the tri-county
area had adequate prenatal care 22% of the time (Figure 4). This reflects primarily Kent
County, since, of the two adolescents in this age group in Ottawa County, none received
adequate prenatal care. For the purpose of this study, adolescents ages 12 to 14 years of
age will be discussed as a group, not according to individual counties, due to the small
number in the sample. There was only one adolescent in Allegan County who was in this
age category, and she received adequate prenatal care. Kent County had a total of 33
adolescents in this age grouping, and 21% (p = 7) received adequate prenatal care. The
other two adolescents between the ages of 12 and 14 were in Ottawa County, and these
two adolescents received intermediate care.

Slightly less than half of the adolescents (46.9%), 15-19 years Of age received

adequate prenatal care in the tri-county area. As can be seen from Figure 5, Allegan and

 

Percentage
2.78%
D Adequate
Intermediate
fl Inadequate
El Unknown

 

 

 

 

55.56%%

Figpte 4. Adequacy of prenatal care received by adolescents ages 12-14 in Ottawa,

Allegan and Kent Counties, Michigan in 1990.

32

  

 

Percentage
Kent County 0‘1 %
43.96%
40.85% ‘ “
Ottawa County Percentage
14.98%
28.34% 54.66%
Percentage
Allegan County 10 17%
53.68%

31.07%

 

 

 

El Adequate
Intermediate
H Inadequate
El Unknown

 

 

 

Cl Adequate
Intermediate
3 Inadequate
1:] Unknown

 

 

 

Cl Adequate

Intermediate

 

22222:. Inadequate

Cl Unknown

 

Figure 5. Adequacy of prenatal care received by adolescents ages 15-19 in

Ottawa, Allegan and Kent Counties, Michigan in 1990.

 

 

 

33

Percentage

2.71%

 

 

 

 

 

 

12.54%
D Adequate
46'93% Intermediate
E Inadequate
37.82% [3 Unknown
5mm. Adequacy Of prenatal care received for adolescents ages 15-19 in combined

Ottawa, Allegan and Kent Counties, Michigan in 1990.

Ottawa were very similar with 55% (p = 95) and 54% (p = 135) of adolescents receiving
adequate prenatal care respectively. Kent county, however, has only 44% (p = 490)
receiving adequate care.

Reseamh Qaesg’on 1p Wha r n f d l 5 nt re iv in rm late r natal care
fer eaeh eepnty?

Adolescents between the ages of 12 and 14 in the tri-county area received
intermediate prenatal care in almost 56% of the cases (Figure 4). Again, this represents
primarily Kent County. Ottawa County had only two adolescents giving birth who were
between the ages of 12 and 14 and both of these adolescents received intermediate
prenatal care. Kent County had 18 adolescents (55%) between the ages of 12 and 14
who received intermediate prenatal care.

In the tri-county area 37.8% (p = 585) of the 15-19 year old adolescents received
intermediate care (Figure 6). Ottawa County, with 28% (a = 70), had the smallest
percentage of older adolescents receiving intermediate prenatal care. Allegan County’s
percentage of 31% (p = 55) was slightly higher, while Kent County had 41% (p = 460)

having received intermediate care (Figure 5).

34
WWh rn f l nr ivineu rnalcare
Mme?

Overall, 19.4% (p = 6) of younger adolescents received inadequate prenatal care, and
these were all in Kent County (Figure 4). About 13% (p = 236) of older adolescents
received inadequate prenatal care in the tri-county area (Figure 6). Kent County had the
largest percentage (15%, n = 114) of 15-19 year old adolescents receiving inadequate
prenatal care. This was followed by Ottawa County with 14.9% (p = 27) of older
adolescents receiving inadequate prenatal care. Allegan County had 10.2% (p = 13) of
older adolescents receiving inadequate prenatal care (Figure 5).

In summary, under one half Of the Older adolescents in the tri-county area received
adequate prenatal care, and slightly over one third of these adolescents received
intermediate prenatal care (Figure 6). Younger adolescents received adequate prenatal
care in slightly less than one-quarter (22%) of the sample reflecting primarily Kent
County. Younger adolescents in the sample received intermediate prenatal care 56% of
the time. Inadequate prenatal care exists for 19.4% of younger adolescents and for

12.5% of older adolescents.

W What pereentage pf pregnant adolescenta in eaeh pf these three
epantjea t'pt'tiated ptenatal eate in eaeh at the nine months pf pregnaney?

Pregnant adolescents in the tri-county area initiated prenatal care as early as the
first month Of pregnancy and as late as the last month of pregnancy with a mean range of
3 to 4.9 months (See Table 3 and 4). Almost 10% (p = 6) had an unknown amount of
prenatal care. Only a few (3 = 6) received no prenatal care at all.

Adeleeeeptag Ages, 12-14. Younger adolescents, ages 12-14 years, initiated prenatal
care late in the first trimester or early in the second trimester. Slightly less than one
quarter (3 = 8) of the 36 adolescents initiated prenatal care in the second or third month
of pregnancy, and slightly less than one third (11 = 11) of the younger adolescents

initiated prenatal care in the fourth month of pregnancy (Figure 7). There was then a

35

 

 

 

Table3

1111111 1"'-;1.1 3.1... .. 1 - -,. 01;”; {1.01. ._; -......,-. .,f-‘ 1111.
.1221
County

Ottawa Allegan Kent All
n a 2 1 33.0 36.0
M b 4 3 4.6 4.9
Median c 4 3 4.0 4.0
SD d 0 o 2.7 3.2

 

aTotal number of pregnant adolescents. bMean month of initiation of prenatal care. cMedian month of initiation of

prenatal care. dStandard deviation of the month of initiation of prenatal care.

 

 

 

Table4

1111111 1'1"-__.111 1.31-2-2. -_-: 1 -.‘ w 01 ‘do; ‘1181.-8W1_ a 11:111- en ounties

ll' 1' . 1229

County
Ottawa Allegan Kent All
11 a 245.0 177.0 1125.0 1547.0
M b 3.3 3.6 3.1 3.5
Median c 3.0 3.0 3_o 3.0

SD 6 2-1 2.6 3.1 2.9

 

1‘Total number of pregnant adolescents. bMean month of initiation of prenatal care. °Median month of initiation of
prenatal care. dStandard deviation of the month of initiation of prenatal care.

gradual decline in number of adolescents initiating prenatal care in the latter months of
pregnancy. According to the MDPH data, one younger adolescent received no prenatal
care (3%). Younger adolescents had prenatal care initiation ranging from the second
month of pregnancy to no prenatal care The mean month of initiation of prenatal care

was 4.9. The median month of initiation for younger adolescents was the 4th month

(Table 3).

36

100.00

00.00

80.00

   

70.00
I Allegan

  

60.00

  
    
 

U Ottawa
Kent

I All

50.00

40.00

 

30.00

Percentage of Adolaaeanta

20.00

10.00

 

0.00

as
N

31d month
4th month
51h month
6th month
7th month
8th month
9th month

None
Unknown

Month of lnItlatlon oi Prenatal Cara

Eigmel. Month of initiation of prenatal care by 12-14 year old adolescents in Ottawa,

Allegan and Kent Counties, Michigan in 1990.

W. Older adolescents, ages 15-19, initiated prenatal care
more often in early pregnancy, than the middle or later pregnancy. The mean month of
initiation was 3.5 for the Older adolescents in the combined tri-county area (Table 3).
Ottawa and Kent Counties had similar months of initiation of 3.3 and 3.1, respectively.
Allegan county had a slightly later time of initiation of 3.6. The pattern of initiation
does, however, vary slightly among the three counties as can be seen in Figure 8.
Fifty-two percent of the older adolescents in the tri-county (n = 818) area received
prenatal care in early pregnancy. Ottawa County had more older adolescents receiving
prenatal care in the first three months of pregnancy (:1 = 99, 61%). Allegan had a
slightly smaller percentage initiating prenatal care in early pregnancy (p = 108, 57%),
and Kent County had 50% (n = 561) of older adolescents initiate prenatal care in early
pregnancy.

The first month of pregnancy had approximately 5% of each of the counties’ older

37

 

 

     
    
 

 

 

 

 

 

 

 

 

 

 

 

   

35.00
30.00 '1
8
5 25.00 -
3 'Ottawa
0
3 20:00 ' 1;; 355*} DAllegan
'5 I ,
3 15.00 - §;§f .KOM
% I a
3 10-00 1
t isl |
5 ~00 I- .1 I :él I
0.00 g is 52 21:" 33f??? .3 I I
e a s s e 5 =
I: c c c 3
i 2 E a a e 2 3 e
35 E 2% e a s s =
Month of lnltlatlon oi Prenatal Care
Figure} . Month of initiation of prenatal care by 15 - 19 year old adolescents in Ottawa,

Allegan and Kent Counties, Michigan in 1990.

adolescents receiving prenatal care. In Ottawa County, almost one third of the
adolescents sought prenatal care in the second month of pregnancy. Slightly less than
one third of the Allegan and Kent County adolescents subsequently presented themselves
in the third month of the pregnancy (Figure 8).

A smaller number of adolescents (36%) initiated prenatal care in the middle of
their pregnancy than those who initiated prenatal care in early pregnancy. Kent County
had a larger percentage of adolescents initiating prenatal care at this time (38%) than
Allegan (27%) and Ottawa County (29%). Over 18% of the Kent County adolescents
initiated prenatal care in the fourth month. In the fifth month of pregnancy, all three
counties had approximately one-tenth of their sample initiate prenatal care.

Initiation of prenatal care in the late pregnancy occurred with approximately 7%
(t1 = 109) of the adolescents in the tri-county area. A considerable higher percentage of

adolescents in Allegan County (p = 17, 9%) initiated prenatal care in the third trimester.

38

Five percent of the adolescents initiated prenatal care in the seventh month of pregnancy.
Again the decline in initiating prenatal care continued during the eighth and ninth months to
1%-2% of the sample. A small percentage of the population received no prenatal care.

Despite the presence of prenatal care in all three counties, there is still approximately
1% of the older adolescent p0pu1ation that is receiving no prenatal care throughout the
pregnancy.

W ai h m n r rnatlvisi eb h a lscent
W?

The mean number of prenatal care visits was not given as a single number, but as a
grouping. In the data presentation, it will be described as groupings that the MDPH utilized.
The range of prenatal care visits for the adolescent population was categorized into seven
groupings by the MDPH. The groupings for the tri-county area ranged from no prenatal
visits to greater than 20 visits and had a bell shaped distribution of this data (Table 5 and 6).

MW. Forty-seven percent of the younger adolescents in the tri-
county area made 10-14 prenatal care visits during their pregnancy. This is approximately
the expected number of prenatal care visits received during a normal full term pregnancy.
Comparing the average range of prenatal visits in each county, Ottawa County had all of
their population receive 10-14 prenatal visits. The younger adolescent in Allegan County
received 5-9 prenatal care visits. Because of the small sizes, two and one respectively,
conclusions should again be guarded (Table 5).

Kent County had a larger sample of adolescents in the 12 - 14 year old category
(3 = 33). The range of visits by the adolescents varied in Kent County, but most adolescents
were either in 5-9 or 10-14 visit intervals (Table 5).

WM. Over one-half of the older adolescent population (54%)
attended 10-14 prenatal care visits throughout pregnancy in the tri-county area. Kent and

Allegan had similar percentages in that grouping, while Ottawa had more (60%) of their
sample in this interval (Table 6).

 

 

 

 

County

Ottawa Allegan Kent All

0' 2 1 33 36
Laws." re a“ 1 a 1 a r 2’;
None 0 o o o 1 3,03 1 2.78
1-4 0 ° 0 o 1 3.03 1 278
5.9 o o 1 100 13 39.40 14 33.33
10-14 2 100 o o 15 45.45 17 47.22
15-19 0 O 0 0 l 3.03 1 2.78
20. o o o o 0 0.00 o 0.00
Unknown 9 0 0 o 0 2 6.06 2 5.56

 

8Total number pegnant adolescents in described area. bTotal number of prenatal care visits documented on birth
certificate that adolescents received during pregnancy. cNumber of adolescents in each county who received prenatal
care based on number of prenatal care visits received. dPercentage of adolescents in each county who received prenatal
care based on total number of visits received. °I'he amount of prenatal care received by the adolescents was not known.

 

 

 

Table 6
'-:,°.-:1-' 0. ’11-:1 .1 V"- u - ' ._ 0di°° I ts'10:w: i.“‘.l 41' ent 0 1' u. I’Llll “0
County
Ottawa Allegan Kant All
:13 245 177 1125 1547

m b f: 33" 1 2'0 1 211 l %
Non. 2 0.82 0 0.00 11 0.98 13 0.84
1.4 9 3.51 10 5.05 53 4.71 72 4.65
5.9 59 24.“ 55 31 .07 345 30.67 459 29.67
10-14 143 3041 95 53.68 598 53.16 841 54.36
15.19 14 5.71 11 6-21 68 6.04 93 6.01
20+ 5 2.04 2 1.13 9 0.80 15 1.03
Unknown . 6 3.27 4 2.26 41 3.64 53 3.43

 

8Total number pregnant adolescents in described area. brotal number of prenatal care visits documented on birth
certificate that adolescents received during pregnancy. cNumber of adolescents in each county who received prenatal
care based on number of prenatal care visits received. dPercentage of adolescents in each county who received
prenatal care based on total number of visits received. eThe amount of prenatal care received by the adolescents was
not known.

40
In the second most frequent interval, (5—9 visits throughout pregnancy) almost one third of

the adolescents in Allegan and Kent Counties subsequently received prenatal care.
Fewer of the Ottawa County adolescents (24%) received prenatal care in that category.
Approximately 7% of the tri-county population had greater than 15 prenatal care visits
during antepartum. This was relatively similar across the three counties.

Although 96% of the adolescents in the tri-county area were able to access
documentable prenatal care, 4% had either no prenatal care or an unknown quantity of
prenatal care. Of this 4%, 3% consisted of adolescents who received a questionable or
unknown amount of prenatal care, while the other 1% received no prenatal care.

Summag

The data for this research consisted of a review of 1990 birth certificate records
from the MDPH data files. Included were the ages of adolescents, amount of prenatal
care received and month of initiation of prenatal care.

Approximately half of all adolescents received prenatal care in the first trimester.
This is consistent in all three counties. Younger adolescents had prenatal care initiation
ranging from the second month of pregnancy to no prenatal care. Older adolescents had
prenatal care that ranged from the first month of pregnancy to no prenatal care. The
median month of initiation of prenatal care for the tri—county area is the third month.

Adequacy of prenatal care is received by slightly less than half of the population
that includes adolescents ages 15-19. Approximately one-third of the adolescents
received intermediate prenatal care. As the adequacy of prenatal care decreased, the
percentage of older adolescents having received that category of care also decreased.

Younger adolescents received more intermediate prenatal care, but three-quarters of
them received less than adequate prenatal care and almost one-quarter of these
adolescents received inadequate prenatal care. There was a small population of younger
adolescents (n = 36), which was more representative of Kent County (3 = 33) than
Ottawa (11 = 2) or Allegan Counties (11 = 1). In Chapter VI interpretation of the results
and recommendations are presented. Implications for advanced nursing practice and

research are also discussed.

MBA/.1

Recommendations, Interpretation, and Implications
v rvi w

The interpretation of the research findings in terms of the conceptual framework,
literature, and methods are presented. Also included is a discussion of the implications
for advanced nursing practice and primary care, and the limitations of the study and
recommendations for future research.

I ' n in in

The research was guided by the Adapted Health Belief Model. Within the
Adapted Health Belief Model, the initiation of prenatal care is identified as the likelihood
of action. The likelihood of action is dependent upon the modifying factors and
individual perceptions of benefits and barriers of the pregnant adolescent. The end result
of the adolescent’s action included how the initiation of prenatal care and the continuity
of care received resulted in the adequacy of prenatal care.

In this study, data were collected on initiation of prenatal care, number of prenatal
visits and adequacy of prenatal care to determine prenatal care utilization by pregnant
adolescents in a tri- county area of Michigan. This section includes interpretation of the
demographic information and findings.

This study was designed to include pregnant adolescents, from Ottawa, Allegan,
and Kent Counties, ages 19 and under, who gave birth in 1990. The Michigan
Department of Public Health provided data which divided adolescents into two age
categories: (a) 12-14 years, and (b) 15-19 years. For the purpose of this study,
interpretation of the findings have been made based on these two age groupings.

The mean age of menarche in the United States is 12.8 years (+/ 2.5 S.D.), with a
normal range of 10.3-15.3 years (Connell, 1992). Studies have shown that one fifth of
the 13-14 year olds and more than half of the 15-19 year olds have begun to have sexual
intercourse (Connell, 1992). Of the total population in this study, 2% (n_= 36) were

41

42
adolescents between the ages of 12 and 14. There are two major factors that could

contribute to this small number. The fust is the physiological development of the
adolescent, and the other is the psychosocial factors that influence adolescents at this
age.

, The mean age of the study sample was 17.8 years. The mean age of pregnancy
in the United States for adolescents age 19 and under is 16.2 years of age (Connell,
1992). The tri-county area has a very strong church basis (Rizzio, 1990a; Rizzio,
1990b). The mean age of onset of pregnancy of this study may be higher because of the
strong religious attitudes towards premarital sex, family stability (I-Iansell, 1991), and
adolescent pregnancy or other social reasons such as availability of birth control and
sexual education in the school system, not addressed in this study (Wells et al., 1990).

Development of independence and self control is a major task among the
adolescent population, and this may be one reason pregnancy may occur among the
adolescent population. The adolescent utilizes decision making to promote the feelings
of independence and control. In terms of adolescent pregnancy, it should be assumed
that adolescents do not choose to become pregnant, rather they choose to become
sexually active, many of whom do not take precautionary measures to prevent pregnancy
(Chandler, Boyes, & Ball, 1990; Offer, Ostrov, Howard, & Atkinson 1990).

Adolescents may feel that they are immune from pregnancy and do not have the
maturity to foresee the potential consequences of their actions (Offer et al., 1990).
Relating to the Adapted Health Belief Model, the adolescent female may, or may not, act
on her knowledge based on her individual perceptions of susceptibility. This may be a
contributing factor to the adolescent pregnancy rate.

Because the adolescent population includes 18 and 19 year old females, these
females are considered legal adults and may choose to be married. Some of the
population in this tri-county area may include young married adults who choose to have

children after marriage. This could contribute to higher statistics in the older adolescent

43
category, however the impact of marriage on the adequacy of prenatal care was not

researched in this study.

Of the total population, 72.7% (n_= 1125) were adolescents in Kent County.
Possible demographic data contributing to the larger percentage of adolescents being in
Kent County are multiple: (a) there are proportionally more adolescents in Kent County,
when compared to Ottawa and Allegan counties; and (b) there is a large inner city
population in Kent County, whereas, Ottawa and Allegan counties have a larger rural
population. Adolescents in Allegan and Ottawa Counties, therefore, may have farm
responsibilities, where as the adolescents in Kent County may have fewer responsibilities
in the home to keep them occupied. Another area where Kent County may differ from
Allegan and Ottawa counties is the possibility that adolescent pregnancy is a family trend
occurring generation to generation (Hansell, 1991).

ni i ' n f Pr n r i

Nationally it has been found that 70% of adolescents receive no prenatal care
during the first trimester, and 25% have prenatal care at the end of their pregnancies if
any care at all (Connell, 1992). When looking at older adolescents in this population, 15-
19 year old adolescents had almost twice the national average received prenatal care in
the first trimester. Over one-half (52%) of the older adolescents (n = 818) sought
prenatal care during the first trimester, and over one third (35%) sought prenatal care in
the second trimester (n = 548).

The reasons for a larger percentage of the sample receiving adequate prenatal
care have not been researched. Speculation includes ability to access earlier prenatal
care when compared to other communities. Another possibility is, despite the
community being conservative, some of the adolescents may be obtaining abortions,
thereby altering the percentage of adolescents initiating prenatal care at different

intervals during pregnancy.

44
Comparing the younger adolescent (£5 36) population, 12 to 14 years of age, with

the national average for adolescents ages 12 to 14, only 22% of the younger adolescents
received prenatal care in the first three months of pregnancy, (3 = 8) and 59% (n: 21)
received prenatal care in the second three months of pregnancy. The mean month of
initiation of prenatal care utilization for adolescents less than age 14 was 4.9 with a
median month of 4.0. This data is similar to the national statistics in reference to
prenatal care (Connell, 1992).

The 15-19 year old sample had a mean initiation of 3.5, similar to the national
prenatal care patterns for older adolescents (Connell, 1992). Older adolescents had a
median month of initiation of prenatal care of 3 and a mean month of initiation of
prenatal care of the third month.

The older adolescents in the tri-county area appear to have better availability of
prenatal care when compared to the national statistics because of improved availability of
prenatal care. However, despite the availability of health care in the tri-county area,
some of the adolescents in this population continued to have delayed entry into prenatal
care. The adolescent, while developing her decision making ability, may not have yet
attained the self confidence to recognize and make decisions related to seeking prenatal
care (Chandler et al., 1990; Offer et al., 1990).

Another possibility for delay in prenatal care may be denial of the pregnancy.
Many young adolescents continue to deny the pregnancy until the latter months of
pregnancy even up until delivery. Fear of punishment, lack of resources and limited
knowledge about bodily changes that occur during adolescence may promote the denial
of pregnancy (Chandler et al., 1990; Hetchman, 1989; Offer et al., 1990) and thus reduce
early entry into the health care system.

A third reason for the delay in initiation of prenatal care may be financial
limitations. In a Johns Hopkins study, adolescents in the program had no health

insurance and no coverage for either health care or hospital bills (Hardy et al., 1989).

45
Johns Hopkins Institute believed these factors may contribute to the delay in entry into

the health care system, or poor compliance with prenatal care visits. It may also be a
contributing factor in this study. The financial limitations of the study population are not
believed to be as great as those in this inner-city program, because the state of Michigan
provides prenatal care regardless of finances. However, it is acknowledged that further
research may reveal some definite limitations pertaining to obtaining financial assistance
for prenatal care among the adolescent population, especially in a primarily rural area
such as Allegan County.

In conclusion, adolescents in the tri-county area are initiating prenatal care at a
variety of times during their pregnancy. This study did not investigate reasons for why
the adolescents chose to initiate prenatal care at the time they did, or if there was a delay
in scheduling the first prenatal visit when contacting a clinic. At this time, only the
research of others can guide the assumptions of why the adolescent made the choice she
did. Further research in the tri-county area should incorporate the adolescent prenatal
care seeking patterns with investigations of the knowledge base of the adolescents and
the decision making process of the pregnant adolescent.

MW

Younger adolescents received adequate prenatal care 22% (1;: 8) of the time and
intermediate prenatal care 55% (g = 20) of the time. Because the young adolescent
population in Ottawa and Allegan County was so small (3 = 3), a comparison of the
individual counties in the tri-county area would not prove beneficial. In Kent County, it
was apparent that younger adolescents received less than adequate prenatal care almost
one fifth of the time. This is the concern, because adolescents less than 15 years of age
are also the population often with more complications related to pregnancy when
compared to the older adolescent population (Atrash et al., 1990). Conclusions in
relationship to patterns of prenatal care of individual counties cannor be made from this

data because of the very small population. However, health care providers should focus

46
the importance of prenatal care to include older and younger adolescents. Different

interventions for adolescents ages 14“and younger may be necessary due to the higher
incidence of complications and the less adequate prenatal care that younger adolescents
tend to receive.

Older adolescents received adequate prenatal care 47% of the time (n = 726) and
38% of the older adolescents received intermediate prenatal care. Again these
adolescents received more adequate prenatal care than the national average.

There is public transportation to enable adolescents to attend prenatal care in
Ottawa and Kent counties. Health department nurses go into the schools to teach young
adolescents about sexual activity in Allegan and Ottawa counties. Health department
nurses and student nurses also visit with pregnant adolescents in the home to help
decrease some of the baniers to utilization of prenatal clinics. Despite alternate forms of
health education there are still difficulties maintaining consistency in prenatal visits
among adolescents. »

In summary, this Was a description of the adequacy of prenatal care of a sample
of 1583 pregnant adolescents in Kent, Allegan, and Ottawa Counties in 1990. It is
assumed that the birth certificate was filled out accurately. This study shows that they
are between the ages of 12 and 19. Younger adolescents had later initiation of prenatal
care, however, it appears that once the younger adolescents are involved in prenatal care
they tend to continue with their prenatal care. Older adolescents initiate prenatal care
over 50% of the time in the first trimester, however, there is decreased attendance to
prenatal care visits by a small percentage of older adolescents.

It is assumed that prenatal care was available to the pregnant adolescent.
However, consideration must be made about the attitude of the adolescent towards
prenatal care and her decision to access prenatal care. Some of the pregnant adolescents
find that they are pregnant they want control over the pregnancy. Some of the

adolescents may take that goal of control over their life and pregnancy and refuse to

47
follow health care recommendations such as deciding not to return for follow-up health

care until they decide that they need health care to be provided to them (Chandler et al.,
1990). Attitudes of the clinic or community may also contribute to the adolescents'
compliance (Chandler et al., 1990; Offer et al., 1990).

Adolescents in the tri-county area are utilizing prenatal care at a slightly higher
rate than the United States average, and it is assumed that pregnant adolescent females
receive prenatal care that is comparable to that of pregnant adult females. However,
adolescent pregnancy continues to be a significant problem in the tri-county area.
Implications for the health care professional include evaluating how difficult it is for the
adolescent to undertake prenatal care with a health care professional. It also includes
educating the public including pregnant adolescents as to the importance of prenatal care,
and investigating the ways and means of improving the utilization pattern by better -
meeting the needs of the adolescent population.

Adequacy of prenatal care in each of the counties was relatively similar (Table 5,
Chapter V). Kent County had a slightly smaller percentage receiving adequate prenatal
care, which gave them a higher percentage in the intermediate category. Other factors
that could contribute towards maternal and fetal health were not taken into consideration.
Therefore, prenatal visits may have altered the adequacy that the adolescent receives due
to complications during pregnancy or early delivery. When the three counties were
compared in reference to month of initiation of prenatal care the mean range for
individual counties was between 3.1 and 4.6 months, and Ottawa County having the
earliest initiation of prenatal care at 3.3 months. The median month of initiation of
prenatal care was around the 3rd month for the older adolescents, and in the 4th month
for the younger adolescents. Because this study was limited to Kent, Allegan, and
Ottawa, the results may not be applicable to other counties.

It is important to note that the differences in the month of initiation is not

practically significant, but that adolescents in all three counties are initiating prenatal

48
care late in the first trimester or early in the second trimester. This is of concern to health

care professionals because of the fetal organogenesis that occurs, and the possibility that
an adolescent may not understand the importance of good health habits throughout
pregnancy.

Again, this researcher did nor investigate reasons why the adolescent made the
decisions she did. A decision was made to use data only provided from the MDPH.
Other demographic data was not included. These factors as well as the adolescents
attitude toward prenatal care could contribute to health care beliefs that influence the
adolescent and her decision making.

n 1 F w
1i 1

The conceptual framework for the research, as shown in Figure 1 (Chapter 11),
offers the adapted Health Belief Model as it relates to pregnant adolescent females. This
study focused only on the end result of pregnant adolescents and the contribution and
adequacy of prenatal care they received. The adequacy of prenatal care depended on
initiation of prenatal care and the number of prenatal visits received. Prenatal care was
identified as the likelihood of action. The likelihood of action is dependent upon the
modifying factors and individual perceptions related to health care and the importance of
prenatal care of the pregnant adolescent female. The end result of the adolescent’s action
included how the initiation of prenatal care and the continuity of care received resulted in
the adequacy of prenatal care.

The conceptual framework was used to explain the amount of prenatal care
obtained by the adolescent population through the concept of likelihood of action. The
likelihood of action was influenced by: (a) perceived benefits of decreasing maternal
and fetal risks, and (b) barriers of demographic, structural and sociopsychological
variables. These issues were not addressed in this study. The Adapted Health Belief
Model used in this study should be revised to better fit this study. Revision of the model

 

 

 

 

 

49

 

 

 

 

 

 

 

 

 

Individual Modifying Likelihood of Resulting
Perceptions Factors Action Action
Maternal | Benefits of Initiation of
Perceptions decreasing Care
_5 h' maternanetal +
°m99rap IC risks Continuity of
Variables ——> Visits
S . h I . Barriers of =
OCIOP§YC ° °9'° Demographic, Adequacy 0’
vanab'es Structural; and Prenatal
' h l ' Care
Structural Soceggzgleosoglc
Variables
j CNS

 

 

Eigum. Adapted Health Belief Model-Revised (Becker 8 Marshall, 1974).

 

50
would have the end result of initiation and adequacy of prenatal care categorized

separately as a resulting action (see Figure 9).

Because there are only about 50% of the older adolescents receiving prenatal care
in the first trimester, and a slightly smaller percentage receiving adequate prenatal care, it
may be because of modifying factors. For those adolescents who did initiate prenatal
care at an early time in pregnancy, it may be that these adolescents perceived prenatal
care as a benefit to their situation. A large percentage of those adolescents became
involved in prenatal care throughout the pregnancy, and knowledge could be a key factor
in understanding the benefit of prenatal care. The demographic variables, interpersonal
variables and situational variables are better described as modifying factors influencing
the adolescents in the tri-county area.

Interpersonal variables, such as expectations of others, influence the individual
perceptions of pregnancy. This, in turn, impacts the adolescent’s likelihood of initiating
prenatal care thereby resulting in an action. Research has shown that pregnant
adolescents are below average in their school performance, coupled with disinterest in
school (Hetchman, 1989). There is a general expectation in Ottawa and Allegan counties
to complete high school. It is assumed that there is not as great as expectation in Kent
county. Because there is an expectation to stay in school, adolescents may delay
pregnancy and take contraceptive action to prevent pregnancy or consent to a therapeutic
abortion to conform to community expectations.

Another modifying factor, social influences such as the media, and peer pressure
to please and be attractive to the opposite sex can influence the onset of sexual activity.
In addition, a larger percentage of adolescents are being raised in single parent
households (Hetchman, 1989). It has been hypothesized that as the single parent of the
adolescent renews interest in dating, this may further influence the adolescent into
similar behavior (Hetchman, 1989). Another example is the adolescent who is currently

living in a disrupted home environment is also more likely to become pregnant. This

51
could be because of the adolescent’s need to feel wanted, or loved or other interpersonal

issues. The adolescent’s home life is marked by poor family relationships, resulting in
the adolescent feeling socially isolated and untrusting (Hetchman, 1989).

Once the adolescent has been influenced by modifying factors in the decision
making phase of the Adapted Health Belief Model-Revised (see Figure 9), the
perceptions of barriers and benefits will influence the likelihood of action. Further
research needs to be done on the adolescent’s perception of prenatal care and how it
affects herself and her child. It is possible that in general those adolescents who
participated in prenatal care had a positive perception of the impact of prenatal care.
Those who chose not to participate could have done so for a variety of reasons. One of
the reasons could be a negative perception of prenatal care. It may be viewed as a
“hassle” or “embarrassing”. The fear of breach of confidentiality is also something that
may bother the pregnant adolescent.

The average age for pregnant adolescents giving birth in the tri-county area is 17.8
years. A study by Barron (1986) found that of the 68 adolescent females who maintained
their first pregnancy, 53 had a second pregnancy as an adolescent. It is probable that a
percentage of the adolescents in the tri-county area may have had prior pregnancies, and
that may influence the health care seeking behaviors. This was not investigated,
however, one may summize that a small percentage of adolescents have been pregnant
more than once before age 19.

Actual barriers to action could also influence the adolescent. There is an average
of 5% unemployment in the tri-county area. For those who are employed, most larger
corporations include health insurance as a benefit and subsequently, the children are
covered for their health care needs until they are 18. For those who have no health care,
the State of Michigan has medical coverage for those pregnant women who are otherwise
unable to afi'ord it. Difficulty accessing health care insurance could influence the

adolescent’s decision to seek out health care. Not knowing that health care is available

52
could be a major factor in deterring adolescents in seeking health care.

It may be that the barrier that would have the greatest influence on the
adolescents in their health seeking behavior is the actual access to health care facilities.
The tri-county area has similarities as well as differences. Each of the countries has at
least one hospital where babies are delivered. Allegan and Ottawa Counties have
antepartum care for routine deliveries. There are two hospitals in Allegan County with a
total of 114 beds. The nearest large medical facility is in Ottawa County. Ottawa County
has over double the number hospitals beds and 179 physicians in the country. This is
four times the number of physicians that Allegan County has. Kent county has a regional
neonatal unit. There are also more physicians advertising “high-risk prenatal care” in
Kent County. Again, Kent County has many times the physicians than Ottawa has and
significantly more hospital beds. Despite the apparent availability of health care, it is
questionable how easy it is to obtain care in the first trimester.

The location of the health care facilities varies in each of the counties. It may be
that the location of the health care facilities does impact health care seeking. However,
the location of the health care provider could be more significant to the pregnant
adolescent female, because many of them may not drive, or have other means of
transportation to health care providers’ offices. This was not researched, and the
information as to the location of all health care providers in the tri-county area was not
easily accessed. Another interpersonal variable for pregnant adolescents is the
interaction with health professionals.

The role of nursing in childbearing once was very significant However, there
was a shift to hospital delivery by physicians at the turn of the 20th century. As
maternity care becomes a team approach, the role of advanced nursing is becoming
increasingly significant once again. As nursing is incorporated into this model, the role
of nursing is visualized as a contributor. The contribution is not only to improve the

adequacy of prenatal care that the adolescent receives, but also impact the individual

53
perceptions, modifying factors, and likelihood of action that the adolescent perceives in

relationship to prenatal care. The CNS can impart the adolescent in all aspects of the
Revised HBM, however, these factors were not addressed in this study (Hansell, 1991;
Offer et al., 1990).

I li ' l' i

Utilizing the nursing process format, implications from this research related to the
nursing practice and the likelihood of action include: (a) determining the role of nursing
in the care and treatment of the pregnant adolescent, (b) development of clinical services
which will encourage the adolescent to seek and remain in prenatal care, and (c)
implementation of a program to incorporate components into a clinical setting.

1i i l r i li

Research about and evaluation of programs providing primary care to pregnant
adolescents supports the use of nurses in advanced practice to improve health and
pregnancy outcomes (Neeson et al., 1983). Nurses in advanced practice tend to relate to
their patients in a nonauthoritative way and focus on education and support for the
pregnant teen (Neeson et al., 1983). The adolescent is still developing her independence
and self control is a major task.

11 l E El . l S .

The data for the tri-county area showed that adolescents received prenatal care
that is more adequate than the national average. Ideally, all pregnant women should
receive adequate prenatal care, however, because some of the population may not
understand the importance of prenatal care, or not be able to afford prenatal care, it is not
likely that the entire population will receive adequate prenatal care in the near future.
However, through concentrated effort of health care forces, the development of
educational programs may improve the percentage of adolescents who receive adequate
prenatal. Specific interventions will be discussed within the role of the clinical nurse

specialist.

54
Especially for the pregnant adolescent female, provisions for adequate care and

ongoing services is critical. The young female patient has multiple and complex
physiological and psychosocial needs. Care for her needs to be focused on the setting in
which multiprofessional groups can be brought together to provide effective care. This
should include teachers, social workers, hospital personnel and health care professionals.
Success of prenatal care programs for the adolescent depend on the following clinical
goals to be included:

(1) Early intervention through early diagnosis and referral. Optimal prenatal care
begins in the first trimester. Adolescents tend to initiate prenatal care at a later point
during pregnancy, in this study, Kent County being the latest. Ideally, agencies who
administer the pregnancy testing to the adolescent should refer the adolescent to a health
care agency for follow-up. In the tri-county areas procedures for referral to an agency
who administers health care to adolescents is unresearched.

(2) A clinical setting in which the adolescent feels that she will be cared for as an
individual (Hansell, 1991; Wells et al., 1990). Staff need to exhibit actions that will be
able to ensure that the adolescent’s privacy, confidentiality, and actions will be respected.
There alreadysexists in the tri—county area a number of schools that incorporate the needs
of the pregnant adolescent, such as facilitating completion of high school requirements.
However, the number of pregnant adolescents allowed in each school is limited.
Therefore not all adolescents would be able to access a program specially tailored to the
pregnant adolescent’s needs. For the adolescents to obtain prenatal care outside a special
school, actual access is questionable. Because of the large number of adolescents
initiating prenatal care in the second trimester, when the adolescent calls a health care
provider to initiate prenatal care, it is not assumed if the health care provider will be able
to establish an initial prenatal care visit with the adolescent in the first trimester. Second
trimester initiation based on ability to access prenatal care could be because of the health

care provider’s policies, or difficulty on the health care provider’s part to be able to give

55
the adolescent an appointment in the first trimester.

In the implementation and incorporation of the components of prenatal care,
numerous programs have been deve10ped across the country (Auterrnan, 1991; Gorsky &
Colby, 1989; Stevens & Pavlides, 1989). These programs have been developed
specifically to improve adolescent outcomes during antepartum. The tri-county area
would benefit from the development of such programs. The implementation and
incorporation of an adolescent pregnancy program in the tri-county area can be based on
many of the roles of the clinical nurse specialist. These would include:

(1) Client Advocate.

Utilization of an advanced nurse practitioner could supply a continuity of care for
the pregnant adolescent. Because Kent county has three teaching hospitals, all with
resident clinics, discussing with residents the importance of adequate time with
adolescents needs to be made. Reinforcing the unique needs of the adolescents also
needs to be an issue of discussion with the residents and staff at the prenatal clinics.
Explanations as to procedures and tests, necessity and patient comfort need also be a
priority. No assumptions about the adolescent’s level of understanding should be made.
Continuity of care should also be attempted.

An orientation session should be conducted by staff that will have continued
contact with the patient. The pregnant adolescent needs to understand the importance of
continuous prenatal care.

In conclusion, as a client advocate, improving the adequacy of prenatal care
utilization among adolescents begins by investigating accessibility of prenatal care by
adolescents in the tri-county area. A second goal is to encourage effective, yet efficient
time with the pregnant adolescent while she is in contact with the health care provider,

thereby possibly improving compliance in prenatal care visits.

56
(2) Educator

Education outside of the office or clinic is also necessary. Nursing education and
experience dealing with community networks, including schools, social services, mental
health and health care centers are essential in order to provide comprehensive care and
appropriate referral of adolescent clients for services.

Radio and television media can be employed to educate the community.
Advertisements inform the community of the availability of prenatal care as well as
educational programs. Announcements focusing on the availability of contraception and
resources for help with pregnancy may increase the perceived availability for the
adolescent, and especially reach the younger adolescents.

Parent teacher organizations are a place to teach the parents what the adolescents
need to be learning. Normal physiology of the adolescent as well as sexually transmitted
diseases are pertinent tapics.

Church related groups are also an area where education needs to be directed.
Church youth groups can have adolescent issues as a focus for their discussions. Again,
contraception, sexually transmitted diseases and adolescent pregnancy can be discussed.

The schools in the tri-county area currently are working with adolescents at two
different grade levels, the sixth and the eighth grades. Because the average age of
menarche is age 12, and many of the sixth graders are 12, the education as to the
physiological and psychological changes that the adolescents are experiencing may be
occurring too late for them to fully benefit, versus if the adolescent begins education
about sexuality at age 10. The CNS can work with the schools as to the importance of
the earlier education, and initiate an earlier ongoing sexuality program for the grade
school children.

When the child enters the middle school, sexuality needs to be presented,
preferably by the same health care professional that discussed sexuality with them in the

grade school. At this time, further discussion as to intercourse and the ramifications of

57
this action will be discussed. Options for counseling outside the school need to be made

available. This strategy provides an option for adolescents to discuss concerns they
have with the health care professional on a one-to—one basis. With the school’s
cooperation, there can be a place in the school, as well as outside the school to give the
adolescent the flexibility to seek the type of additional needs they have. High school
students need information about developmental changes in adolescence, intercourse,
sexually transmitted diseases and the physiology of pregnancy. This needs to include
options that the adolescent has, once she has an unplanned pregnancy and education as to
the importance of prenatal care during antepartum.

Another educational tool which could be developed is a sexuality hotline
sponsored by major hospitals and health care providers in the tri-county area. Phone
calls from those who are not able or willing to come to a meeting can receive information
relating to sexuality related issues. Pregnancy related questions can be addressed as well
as preventative education. In addition, the educational needs of the pregnant adolescent
within the health care system care system need to be addressed in a variety of methods
including one-on-one teaching as well as small group discussions. Nutrition, human
sexuality, family planning, preparation for labor and delivery, infant care and feeding,
and maternal expectations can be implemented (Hetchman, 1989).

Improved education in the community will decrease the possibility that the
inadequate prenatal care that adolescents are receiving is due to a knowledge deficit. It
will also improve accessibility to knowledgeable sources.

(6) Evaluation.

Because of the apparent later initiation of prenatal care in Kent County, practices of
health care providers in the tri-county area need to be assessed. Evaluation as to the
cause of the delay in prenatal care needs to be researched. The question of health care
providers’ encouragement of initiation of prenatal care in the first trimester needs to be

answered. One possible factor contributing to the delay of prenatal care is the practices

58
of the health care providers. If later initiation is the policy of health care providers, the

health department, CNS, and the health care community need to work together to change
that policy.

In summary, the research findings of adequacy of prenatal care were descriptive
with the potential for nursing to impact these finding by improving the accessibility of
prenatal care to the adolescent population through measures such as previously
mentioned (Auterrnan, 1991; Gorsky & Colby, 1989; Hardy et al., 1989; Stevens &
Pavlides, 1989; Youngs & Marean, 1989). While the findings from this study are
descriptive only, implications about the primary care role of nurses include provision of
support and collaboration with the educational system. It also reinforces a continuing
goal for nursing education of health care providers related to the care of the pregnant
adolescent. In the next section of this chapter implications for future research are
presented.

Rggmmendatigns for Future Nursing Research
A number of implications for further research may be derived from this study.
Suggestions for improvement of design of this study include implications with barriers,
benefits and perceptions of prenatal care and pregnancy.
W

W. A prospective study of adolescents is suggested so that reasons
for adequacy of prenatal care can be investigated. The adolescent makes her decision for
prenatal care, depending on the benefits of decreasing the maternal and fetal risks that
she perceives and the perceived barriers she experiences in seeking out prenatal care
(Hansell, 1991; Hetchman, 1989). Because there are only about 50% of the older
adolescents receiving prenatal care in the first trimester, and a slightly smaller percentage
receiving adequate prenatal care, it may be that this is because of the benefits and
barriers that the adolescent perceives. In a prospective study, the barriers and benefits

can be addressed as they develop.

59
W. A questionnaire can be developed to explore reasons for

initiating or ceasing prenatal care. The data received can be shared with local health
departments and health care providers in an attempt to identify and correct some
barriers in the community.
2mm

Adolescents' perceptions of pregnancy and prenatal care need to be collected
throughout the prenatal period to evaluate the possible fluctuations in adolescent
attitude towards prenatal care.
Demographics

Information related to demographics of the population can be investigated in the
future to possibly find a correlation between socioeconomic level, race, and living
location to adequacy of prenatal care obtained. A second study utilizing the same
research questions can be done to evaluate if this study was a single occurrence or a
trend.

Summary

In Chapter VI a summary and interpretation of study findings was presented.
Adolescents had later initiation of prenatal care in Kent County, when compared to
Allegan and Ottawa County. Adequacy was also somewhat more inadequate when
compared to Allegan and Ottawa Counties. This was evident among younger and
older adolescents.

Modifications in the conceptual framework were made to change the focus of
health care. The Adapted Health Belief Model was primarily illness prevention. The
Adapted Health Belief Model was revised.

Recommendations for future nursing research were made. These include
working to improve accessibility and availability for the adolescent population,

teaching the community about prenatal care and its importance, and the further

60
evaluation of current prenatal care access in the tri-county area. These

recommendations also include researching, barriers and benefits, perceptions during

antepartum and further demographic variables.

APPENDIX A

Appendix A

Letter of Request for Data

“KR".
«‘4

January is. i....

Office of the State Registrar and Center for Health Statistics
Department of Public Health

3423 N. Logan/Martin L. King Jr. Blvd

PO. Box 30195

Lansing, Michigan 48909

Dear Ms. Humphry:

As discussed on the phone. i am a Master's student working on a thesis
with a specific focus of the adequacy of prenatal care of the adolescent
based on Kessner's index. i would like to Include in my analysis all births
to females 19 years of age and under in the counties of Kent, Allegan, and
Ottawa counties for the most recent year that statistics are available. We
had discussed including the elements of onset of prenatal care. number of
Drenatal visits. level of prenatal care based on Kessner's index and age of
mother in the aggregate format. After further discussion with my thesis
commltee. the elements of number of prior pregancies and gestational age
of infant at birth are also requested.

With our phone call. you had said to request the data. and if their was a
cost. you would let me know.

Please feel free to call me if you have any questions in reference to my
request I can be reacts-d at work at (S I 7) 52 l -39S8.

Sincerely,

Sonia D 'Jan Eyl Taylor
4609 Devonst
Lansing, Michigan 48910

61

APPENDIX B

Appendix B

Letter of Available Data from the MDPH

“._.1.
l.

STATE OF MICHIGAN

@
JAMES J. BLANCHARDFGovomor

DEPARTMENT OF PUBLIC HEALTH

3423 N. LOGAN/MARTIN L. KING JR. BLVD.
P.O. BOX 30195. LANSING. MICHIGAN 48909

September 16, 1991

Sonia Taylor
4609 Devonshire
Lansing, MI 48910

Dear Ms. Taylor:

I am writing in response to your inquiry concerning the availability of
live birth data. All of the data elements mentioned in your letter
(onset of prenatal care, mean number of prenatal visits, level of
prenatal care, age of mother) are available in an aggregated format. The
latest year of data we have is 1989. The birth certificate is the sole
source of the data. I’ve enclosed a record layout and code book to
assist you in deciding on the tabulations you will need for your thesis.
If you have any questions I can be reached at (517) 335-8714.

Sincerely,

910. i, Jalumm'

Kathy S. mphrys

Statistician

Office of the State Registrar and
Center for Health Statistics

62

APPENDIX C

Appendix C

Letter of Approval from UCRIHS

MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE PRESIDENT FOR RESEARCH FAST [ANSING ' MICHIGAN - “Illa-I016
AND DEAN OF THE GRADUATE SCHOOL

March 3, 1992

Sonia Taylor
4609 Devonshire
Lansing, MI 48910

RE: THE PATTERN 0F PRENATAL CARE UTILIZATION OF PREGNANT ADOLESCENT FEMALES IN
A TRI-COUNTY AREA IN SOUTHWESTERN MICHIGAN, IRB #92-055

Dear Ms. Taylor:

The above project is exempt from full UCRIHS review. The proposed research
protocol has been reviewed by another committee member. The rights and welfare
of human subjects appear to be protected and you have approval to conduct the
research.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate UCRIHS approval one month prior to February 28, 1993.

Any changes in procedures involving human subjects must be reviewed by UCRIHS
prior to initiation of the change. UCRIHS must also be notifed promptly of any
problems (unexpected side effects, complaints, etc.) involving human subjects
during the course of the work.

Thank you for bringing this project to my attention. If I can be of any future
help, please do not hesitate to let me know.

Sincerely,

M“

 

Human Subjects (UCRIHS)
DEW/deo

cc: Dr. Mildred Omar
Dr. Rachel Schiffman

63

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