u- .. .mvfiunrfiu, :31: A?» ..;m.:.... H4. 9‘»... .t. A v..n...._a.:u.en. : U..J.:«..¢..a . , 9?... 5g. } 4&5... 2.! 1.2:). isalili u\ a: s. .2: e. 2...! .3... J. :2 i .. .. .31... xi... 31/... .A $555.“ 2 :3?! a E... .91 .. 1. 1).): an}? 3. a: 15‘ 3 \ I » {tn 1»:- 2:...7: .. 3 .1. i. ?. .. 3 KW: L . {F t. Lwfifih 1....“ .2... 2 . i. h m‘ 1...... .9“: B. .... r... x. ). n‘!rv..r :. I: \a I Fall vc’ ‘In‘ fly 1 ’1. )1?!» m“ lllllllllfllllllfllllllllllilllilll ’ ,- 3 1293 01410 0584 This is to certify that the thesis entitled THE RELATIONSHIP BETWEEN PRENATAL CARE AND THE SIZE AND COMPOSITION OF THE SUPPORT NETWORK presented by Anne M. Colby has been accepted towards fulfillment of the requirements for Master degree in Science Kw I Major rofessor Rachel Schif man, RN, PhD. DateW 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State University PLACE II RETURN BOX to romovo this checkout from your record. TO AVOID FINES rotum on or baton date duo. DATE DUE DATE DUE DATE DUE WM! THE RELATIONSHIP BETWEEN PRENATAL CARE AND THE SIZE AND COMPOSITION OF THE SUPPORT NETWORK BY Anne M. Colby A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1995 ABSTRACT THE RELATIONSHIP BETWEEN PRENATAL CARE AND THE SIZE AND COMPOSITION OF THE SUPPORT NETWORK BY Anne M. Colby This ex post facto descriptive study, examined relationships between.prenatal care adequacy and the size and composition.of the support network of 108 low income pregnant women. Secondary analysis was employed using data obtained from a private, not-for-profit comprehensive prenatal care center. Data from the Norbeck Social Support Questionnaire and center prenatal care records were used in eweluating the support network and prenatal care adequacy. Using chi-square statistical analysis, no significant relationships were identified between the size and composition of the support network and adequacy of prenatal care. Concepts related to the utilization of prenatal care must continue to be explored in order to improve utilization. ACKNOWLEDGEMENTS I would like to express my appreciation to my thesis committee for their time and willingness to share their vast knowledge with me throughout the thesis process. To: Rachel Schiffman, R.N., Ph.D., my committee chairperson, for her guidance throughout the "unfolding" of my thesis. Linda Beth Tiedje, R.N., Ph.D., for her excitement about the thesis early in the process. Jacqueline Wright, R.N., M.S.N., for her reality based questions. I would also like to express my heartfelt appreciation to my family without whom none of this would be possible. To my husband Terry who believed in me when I would have given up. To my sons, Joshua, Jeremy, and Shane who helped me to laugh even before deadlines. Thank you to my church family and youth group, for your prayers and encouragement. Praise to my Heavenly Father who is my strength and my shield. Lastly, I would like to thank my study group, Mary Ann, Marilyn, Mary Ann, Marj, and Connie who supported, laughed, cried and complained. with. me, as we ventured onto new horizons. iii TABLE OF CONTENTS }List of Tables List of Figures Introduction Statement of the Problem Conceptual Definition of the Variables Adequacy of prenatal care Support Network Conceptual Framework Review of Literature Adequacy of Prenatal Care Size of Support Network Composition of Support Network Critique of the Literature Methods Design Sample Operational Definitions Instrument Data Analysis Human Subjects Approval Assumptions and Limitations Results Sample Description . Results of Analysis for Research Questions Discussion Interpretation of Findings Problems with Data Analysis Adequacy of Prenatal Care, Size and Composition of the Support Network Conceptual Model iv vi vii 16 21 ll 23 24 25 27 27 27 28 32 33 34 35 36 36 36 42 42 44 46 49 Implications . . . . . . . Advanced Nursing Practice Research Summary Appendix A - UCRIHS Approval Appendix B - UCRIHS Approval for Original Data Appendix C - Norbeck Social Support Questionnaire: Part used for Support Network Data References 50 50 52 53 55 56 57 58 Table Table Table Table Table Table Table Table Table Table 10. LIST OF TABLES Month of Initiation of Prenatal Care Categories Recommended Visits by Week of Gestation-Summary Adequacy of Prenatal Care Utilization Index-Expected Number of Visits Summary Adequacy of PNC Utilization Index Based on PNC Initiation and Received Services Sample Characteristics The Frequency and Percent of the Size and Composition Groups Frequency and Percentage of Prenatal Care Adequacy Groups Cross Tabulation of Adequacy of Prenatal Care by Size of the Support Network Cross Tabulation of Adequacy of Prenatal Care by Composition of the Support Network Cross Tabulation of Adequacy of Prenatal Care by Combination of Size and Composition Groups vi 7 9 10 3O 37 38 39 39 41 41 FIGURE Conceptual Model for the Study of the Relationship between Prenatal Care and the Size and Composition of the Support Network vii 18 1 Introduction The infant mortality rate (IMR) in the United States continues to lag behind most other developed countries. In 1993, the IMR reached an all time low of 8.28 per 1,000 live births. However, twenty-one other countries through out the world still have rates lower than the United States (Wegman, 1994). Hubert Humphrey once said, "It has been said that the moral test of government is how that government treats those who are in the dawn of life-the children; and those who are in the shadows of life—the sick, the needy, and the handicapped," (Congressional Record, 1977). If one is to examine how fragile members of this society are treated, only unfavorable conclusions could be made. In the United States, special populations of needy children, the minorities, the poor, and/or rural inhabitants, have IMR's that are not only higher than the overall United States IMR, but have rates that are similar to IMR's in developing countries. Consequently, much national debate is occurring regarding how the United States can best tackle the infant mortality problem. There is not likely to be one lone solution for the infant mortality problem; it is too multifaceted. Only through research will specific information regarding the relationships among the variables associated with such a complex problem as the IMR be identified. Variables such as adequate prenatal care and adequate maternal social support 2 have been repeatedly associated with improved IMR’s in the literature and need further investigation in order to maximize the impact they can have on the IMR. It was the purpose of this research to examine the relationships between certain aspects of these variables, the adequacy of prenatal care and one component of social support, the support network. Statement of the Problem Although some progress in decreasing the IMR has been made, much of it is attributed to improved outcomes for low birthweight (LBW) infants admitted to neonatal intensive care units (NICU). While NICU care is very expensive, prenatal care (PNC) is commonly believed to be cost effective in preventing infant mortality (Aved, Irwin, Cummings, & Findeisen, 1993; Brown & Ryan, 1992; Buescher, Roth, Williams, & Gofoth, 1991; Foster, Guzick, & Pulliam, 1992; McClanahan, 1992), but the reason for this is unclear. Although PNC is believed to be an effective prevention for low birthweight (LBW) and LBW is believed to be the major contributor to the IMR (Goldenberg, 1992; Malloy, Kao, & Lee, 1992; McCormick, 1985; Schwartz, 1990), it appears that the effect of prenatal care on the IMR is multifactorial. It includes not only the early diagnosis of complications such as pre-eclampsia, pre-term labor, intrauterine growth retardation or gestational diabetes, but also other factors, such as the evaluation of the adequacy of the woman’s 3 support network. When problems are diagnosed early, whether they are physical or psychosocial, interventions are then able to be implemented to impact the problem before it becomes critical. However, for both assessment and intervention to take place, the woman must be involved first in primary care, and then in PNC enough to provide adequate opportunity for their occurrence. If the use of PNC is associated with reduced infant mortality, then the reasons why women are not obtaining this cost—effective, preventive care must be examined. Several authors have explored the barriers that inhibit the use of PNC (Aved et al., 1993; Goldenberg, Patterson, & Freese, 1992; Oxford, Schinfeld, Elkins, Ryan, 1985). The most commonly identified factors could be grouped into three categories: demographic, situational and psychosocial variables. Little is really known about this last category, and even less about the specific aspects of psychosocial concerns. While there has been some research that suggests that social support positively impacts health (Cliver et al., 1992; Culpepper & Jack, 1993; Kahn, 1979; Kaplan, Cassel, & Gore, 1977; Norbeck & Anderson, 1989; Nuckolls, Cassel, & Kaplan, 1972; Villar et al., 1992) there is a paucity of information regarding the support network and prenatal care. This study investigated, through secondary analysis, if one concept of social support, the support network, was related to the use of prenatal care in a group 4 of pregnant women in a southern Michigan county. The research questions were: 1.) Are there differences in the adequacy of care patterns among women with high numbers of people in their support network and those with few in their support network? 2.) Are there differences in the adequacy of care patterns among women with heterogeneous versus homogenous compositions of support networks? 3.) Are there differences in the adequacy of care patterns among women who have high and low numbers and different compositions of support networks? Conceptual Definition of the Variables Adequacy of Prenatal Care There has been much discussion about the adequacy of PNC in the literature. Adequacy defined in quantitative terms constitutes the majority of that discussion, while the qualitative components have been less widely explored. The American College of Obstetricians and Gynecologists (ACOG) offers standards for PNC (ACOG, 1989). These standards suggest not only the quantitative aspects of PNC, but some of the qualitative components as well. Although the general goals of prenatal care are to provide risk assessment, treat identified conditions, and to educate pregnant women about risk factors, pregnancy care, and infant related issues (Goldenberg, 1992), how each provider accomplishes this is individualistic. This makes attempts at identifying the 5 qualitative variables such as the content of patient education or emotional support provided at a visit difficult at best. Consequently, many authors discuss PNC in quantitative terms only (i.e., number of visits). This approach assumes that when PNC has started early and a certain number of visits have occurred, that the minimal goals of PNC will have been met to some degree. For the purposes of this study, the adequacy of prenatal care was defined in quantitative terms only. Kessner, Singer, Kalk, and Schlesinger (1973) proposed an index for measuring the adequacy of PNC that has served as the foundation for quantifying adequacy. It is based on three parameters: (a) trimester at which care began, (b) the number of prenatal visits, and (c) gestational age at delivery. Adequate care for this index was defined as care beginning in the first trimester and following the ACOG recommended number of visits for gestational age. This approach assumes that the earlier PNC is initiated the more likely it is that care will be adequate. ACOG (1989) recommends that a woman be seen every four weeks for the first 28 weeks of pregnancy, every two to three weeks for 28 to 36 weeks of pregnancy and once per week thereafter. This would suggest approximately 14 visits for a 40 week pregnancy, and assumes that effective PNC must be continuous. The gestational age at birth component attempts to adjust for the obviously smaller number of visits in 6 premature births. Without this factor, erroneous conclusions could be reached that preterm birth is caused by inadequate PNC when in fact, preterm birth precludes a woman from obtaining the adequate number of visits. Alexander and Cornely (1987) revised the Kessner index to address some of its limitations and included three other groups, an intensive care group in which more than the expected number of visits in a single pregnancy was considered, a no care group and a missing data group. The authors felt that these three additional groups were inherently different and could be responsible for some of the conflicting results obtained with the Kessner index. The authors viewed the intensive care group conceptually as potentially having more morbidity or complications. Through examination of this group an attempt was made to see if women who obtained more PNC and were inherently more prone to morbidity were skewing adequacy research. While this index attempted to separate for some of the confounding variables potentially present in the different groups, it still defines adequacy primarily based on the timing of initiation of care. For PNC to be classified as adequate, care must have begun in the first trimester. Kotelchuck (1994c) proposed an index, the Adequacy of Prenatal Care Utilization Index (APNCU) that addresses some of the limitations of the previous two indices. The APNCU 7 utilization of received services, and captures the essence of the pattern of PNC utilization. The first concept, initiation of care, is described in terms of two month segments for the first two trimesters (see Table 1) making four initiation categories instead of three trimester divisions, and citing the idea that the second trimester covered too broad a time period to adequately evaluate PNC initiation. Adequate Care For the purposes of this study, adequate care was defined as a pattern of care that is initiated early, by the end of the fourth month, and is continuous throughout the pregnancy. Table 1 Month of Initiation of Prenatal Care Categories Month care initiated Adequacy 1-2 Adequate 3—4 Adequate 5-6 Inadequate 7-9 Inadequate 8 differentiate between patterns of care that may yield the appropriate number of visits based on gestational age at delivery, but were initiated after the fourth month, from those in which care was initiated early and then remained continuous. Kotelchuck (1994c) defines adequate care as care beginning by the end of the fourth month of pregnancy and meeting 80-109% of the recommended number of visits adjusted for gestational age at delivery. Adequate plus care meets the adequate definition, but exceeds the expected number of visits by 110% or greater. Intermediate care is defined as also beginning by the end of the fourth month, but meeting only 50-79% of the expected number of visits. Inadequate care is defined as care beginning after the fourth month of pregnancy and/or meeting less than 50% of the expected number of visits. Adequacy of PNC was defined in this study as according to parameters identified by Kotelchuck (1994c) with initiation of care and frequency of care adjusted for gestational age. Adequate Care For the purposes of this study, adequate care was defined as a pattern of care that is initiated early, by the end of the fourth month, and is continuous throughout the pregnancy. Table 2 Recommended Visits by Week of Gestation - Summary Weeks Gestation Recommended Visits N =37+ (+ (N-36)) visits 37 11 Visits 36 10 visits 34-35 9 visits 32—33 8 visits 30-31 7 visits 26—29 6 Visits 22-25 5 visits 18-21 4 visits 14-17 3 visits 10—13 2 visits 6- 9 1 visit Note. Table from Adequacy of Prenatal Care Utilization Index: Technical Details and Rationale, by Kotelchuck, M., 1994b. Unpublished manuscript, University of North Carolina at Chapel Hill. 10 Table 3 Adequacy of Prenatal Care Utilization Index — Expected Number of Visits Month PNC Gestational Age LBeanflfligflfléifiiiléfllé 9 _ .. _ _ _ _ - _. _ _ _ 8 - - - - - - l 1 l 2 3 7 - - 1 l l 1 2 2 3 4 5 6 1 1 1 1 2 2 3 3 4 5 6 5 1 1 2 2 3 3 4 4 5 6 7 4 3 3 4 4 5 5 6 6 7 8 9 3 4 4 5 5 6 6 7 7 8 9 10 2 5 5 6 6 7 7 8 8 9 10 ll 1 6 6 7 7 8 8 9 9 10 11 12 Note. Table from Adequacy of Prenatal Care Utilization Index: Technical Details and Rationale, by Kotelchuck, M., 1994b. Unpublished manuscript, University of North Carolina at Chapel Hill. 11 Adequate Plus Care Adequate plus is defined as care that exceeds adequate care. It is begun by the end of the fourth month and exceeds the expected number of PNC visits for gestational age. Intermediate Care Intermediate care is defined as care that is initiated early, begun by the end of the fourth month of pregnancy, but is not consistent enough to be considered adequate care. Inadequate Care Inadequate care is care that is not initiated by the end of the fourth month of pregnancy and is not consistent and/or frequent. Support Network The concept of social support began to be discussed widely in the literature in the 1970’s. It is defined in many different ways by different authors. Although the term support network is not defined in all these studies, it is sometimes discussed by virtue of how support is defined. Nuckolls, Cassel, and Kaplan (1972) suggested that the support network, was a component of psychosocial assets. While support network per se was not defined, psychosocial assets were operationally defined in terms of self, marriage, extended family, social resources (included friendship patterns) and the definition of pregnancy. Three of the assets could be considered components of the support 12 network: marriage, extended family, and friendship patterns. Kahn (1979) defined his concept of "convoy" as consisting of a set of people on whom an individual relies for support and those who rely on that person for support. He further defined social support in terms of interpersonal transactions that consist of affect, affirmation, and aid. Affect was defined as expressions of respect, admiration, and liking. Affirmation represented agreement with others, and aid represented assistance through means of information, material goods, or personal time. In all these definitions, the concept of a support network is implied. Without a network of individuals to provide assistance whether it be affect, affirmation or aid, the pregnant woman may be unable to obtain the care she needs (i.e., transportation to PNC, baby—sitting for older children during her appointment). Much of the work of the eighties was based on Kaplan's (1977) and Kahn’s (1979) classic studies from the seventies. Norbeck, Lindsey and Carrieri (1981) based their personal network definition on Kahn’s work when operationally defining personal network as "...each significant person in your 1ife...all the persons who provide personal support for you or who are important to you now." (p. 65). Mercer and Ferketich (1988) define network support as social embeddedness and having to do with "connections that people have with others in their environment" (p. 27). Aaronson (1989) discussed the distinction between perceived and 13 received support, and postulated the idea that support cannot be received if it is not perceived to be available from members of a woman’s social network. May (1992) defined social network as "the people important to an individual". The underlying assumption in these definitions is that a vital component of support is the support network. For the purposes of this study, a combination of the definitions of May (1992) and Mercer and Ferketich (1988) was used. Support network was defined as, self reported connections that an individual has to people in their environment who are important to that individual. It was discussed quantitatively in terms of size and qualitatively in terms of composition of relationships identified in the support network. However, with this definition, it is understood that no distinction can be made between the actual presence of support and the perception that support is present. Size of support network While several studies report network size in the course of their analyses (Barrera, 1981; May, 1992; Mercer & Ferketich, 1988; Norbeck & Anderson, 1989; Norbeck, Lindsey, & Carrieri, 1983), May came the closest to conceptually defining the concept of size. She identifies the number of network members as buffering the effects of stressful events. The idea of a larger network providing more support is conveyed. Whether the relationship between size and 14 support is a result of simply having more people to draw support from at any given time, or the result of the diversity of the human being, and having a broader base of human qualities to draw from is not known. Because no two individuals are exactly alike, there is some degree of increasing heterogeneity involved in having higher numbers of people in a support network. While other studies do not define the concept of size of the network, it was felt to be important in the present study to examine this tangible, measurable component of support. The literature describes an average sized network to have between seven and eight members (Mercer & Ferketich, 1988; Norbeck, Lindsey, & Carrieri, 1983). For the purposes of this study network size is defined as the total number of individuals the respondent identifies as being in their support network. Low numbered group. A low numbered group was defined as less than the average sized group, and assumed to be fewer than necessary to provide adequate support. High numbered group. A high numbered group was an average sized group or larger and assumed to be large enough to provide adequate support. Composition of support network The concept of composition of the support network has not been commonly defined in the literature. Collins, Dunkel- Schetter, Lobel, and Scrimshaw (1993) defined network resources as living with the baby's father, and having one 15 relative and one close friend in the area. While this does not define composition per se, it does offer one potential combination of a heterogeneous group. Norbeck et al. (1981) describe the support network as being comprised of the significant persons in an individual's life. While several authors have mentioned certain relationships like significant other, family, and friends (Collins, et al., 1993; Mercer & Ferketich, 1988; May, 1992; Norbeck & Anderson, 1989; Norbeck et al., 1983; Nuckolls et al., 1972) only a few include more diverse relationships such as work or school associates; neighbors; health care providers; minister/priest/rabbi; counselor/therapist; or other (Mercer & Ferketich, 1988; Norbeck & Anderson, 1989; Norbeck et al., 1983). The most commonly identified relationships have been the spouse or significant other, family, and friends (Mercer & Ferketich, 1988; May, 1992; Norbeck & Anderson, 1989; Norbeck et al., 1983). Although Mercer & Ferketich (1988) did not report family as a group, they listed each family relationship separately, their category of mother, was reported in the top three with spouse/significant other and friends. While diversity in the composition has not been conceptually defined, it seems plausible that a diverse network could "balance out" the ill effects created by particular members of a network. Aaronson (1989) found that women who perceived support from individuals who smoked, or drank alcohol or caffeine were more likely to exhibit those l6 behaviors themselves. With a more diverse network, perhaps enough support would be perceived from individuals with healthy behaviors to counteract the support perceived for unhealthy behaviors. It also seems credible that diversity could serve as a safety net in the event that whole groups of support people (i.e., family, friends, work associates) became unavailable. Homoqenous composition. For the purposes of this study, a homogenous composition was defined as containing none or only one type of relationship (i.e., only family members or only friends or only professionals). It is assumed that if all of this one type of relationship comprising the whole of a person’s support network, were to cease to exist, the person would no longer have a support network (i.e., if a woman only had family support, and she became estranged from her family for some reason). Heterogeneous composition. A heterogeneous composition was defined as containing more than one type of relationship (i.e., family, friends and neighbors, professionals, or others). It is further assumed that if one type of relationship, for example family, were to cease to exist, that there would still be other members, for example friends, in the person's support group. Conceptual Framework Martha Rogers' Science of the Unitary Human Being (Fawcett, 1989) was selected to explain the relationship 17 between the variables of adequacy of prenatal care, and the size and composition of the support network. When dealing with components of social support like support network, a certain level of abstraction is necessary. Rogers’ model is "a synthesis" (Fawcett, 1989) of systems theory, physics, mathematics, and nursing knowledge. The basic concepts of energy fields and pattern are the foundations for her model. She defines an energy field as the fundamental unit of the living and the non-living (Barret, 1990). It is described as being dynamic, in constant motion, and infinite. Pattern is defined as the "distinguishing characteristic of an energy field perceived as a single wave" (Barret, 1990). Energy field and pattern serve as the foundation for defining the person and the environment. The person is defined as a Unitary Human Being in which he/she is a pattern, an "expression of life process" and "greater than and different from the sum of its parts" (Garon, 1992). This holistic, timeless view of the individual through the "kaleidoscope" of the whole person allows for some understanding of the illusive, complex nature of humans. During pregnancy, a woman’s pattern continues to evolve, a separate yet integrated pattern unfolds within her, that of the fetus. The changes manifested in her pattern then affect her environment through the process of integrality. Integrality addresses the continuous interchange between the person and the 18 environment. Barret (1990) defines integrality as "continuous mutual human field and environmental field process" (p. 388). Rogers' views the environment also as a pattern that is "irreducible" and "indivisible" from the human energy field (Garon, 1992). This environmental energy field is composed of, but greater than, anything that interacts with the human energy field. It also is identified by pattern and is integral with the human energy field. Prenatal care satisfies the definition of an energy field in that it is dynamic, in continuous motion and infinite (see Figure 1). Adequacy then, is defined as a pattern of that energy field. While prenatal care is itself a part of the larger environmental energy field, the behavior of the woman to obtain adequate care is what creates the pattern of adequacy within that environmental field, further demonstrating the principle of integrality. Because the pattern of PNC is not known or anticipated for the different components of the support network, it can not be visualized in the model. It is as an energy field that the concept of a support network is also understood, again as an energy field within the larger environmental field. As the individual interacts with her support system, whether that be with family, neighbors, or health care providers there is a continuous inter-field process that occurs in which the individual and her environment are constantly exchanging. This energy 19 CONCEPTUAL MODEL / . . // Env1ronmental Energy Field. \\ \ ///10uestion 1 Question 2 \\ /:/ PNC / Pattern ‘ {Erggna—t_ Human BeingJ \\ PNC /// ‘\ Pattern Pattern /, .———_ -—-"‘"'// "‘ ”;*~‘ ---~ ~\ \ / - - \ Env1ronmental Energy Field / \ Question 3 l/ \ \ / / Pattern I nant Human-_Be1ngj Legend \ 2 Pattern W=High numbers \\ /~\J/=Low numbers \‘\ Pattern ’/ \ // W=Heterogeneous composition \—_..__._ _. ._._.. ..... / .£_2_=Homogenous composition Figure 1. Conceptual Framework for the Study of the Relationship between Prenatal Care and the Size and Composition of the Support Network. 20 field of the size and composition of the support network can be envisioned as a bridge between the woman and PNC adequacy patterns (see Figure 1). The form of the "bridge" also demonstrates the concept of helicy. Helicy describes the "continuous innovative, unpredictable increasing diversity" of the human and environmental field patterns (Barret, 1990). This principle addresses both the size and composition components of the support network. The support network energy field, assumes a different pattern based on the particular characteristics of the support network. With higher numbers of support people identified within the support network, there is more diversity (heterogeneity) within both the human and environmental field patterns, this can be pictured as a high amplitude, frequent wave pattern (see legend Figure 1). Low numbers of support people would then be seen as a small amplitude, infrequent wave pattern (see legend Figure 1). When there are heterogeneous compositions of the group, helicy is once again demonstrated. However, to distinguish between the size and composition patterns in the model, a spiral will be used to demonstrate the composition pattern, with the more tightly coiled spiral pattern representing the heterogeneous composition, and the loosely coiled pattern representing the homogenous composition (see legend Figure 1). Because it is not known what, if any, relationships exist between the size and composition of the support group 21 and PNC utilization, the four utilization patterns, Adequate Plus, Adequate, Intermediate and Inadequate are not specifically identified in the model. It would be difficult to identify these different patterns without projecting a relationship. Review of Literature An extensive review of the literature regarding PNC adequacy, and support networks, particularly in pregnancy, was conducted. There was little information on both variables examined together, consequently studies in which some aspects of PNC or social support are discussed were included. Adegpacy of Prenatal Care There is a wealth of information regarding the adequacy of prenatal care. It has been discussed from many different points of View, including both qualitative and quantitative aspects. There have been at least three large studies using vital statistic information in which indices quantifying adequacy have been developed (Alexander & Cornely, 1987; Kessner et al., 1973; Kotelchuck, 1994a). In each of these studies adequacy was compared to birth outcomes such as birthweight, gestational age at delivery and/or neonatal mortality, with less than adequate care groups having worse neonatal outcomes. Additionally, Kessner et al. reported adequacy compared to the variable of race, and Alexander and Cornely compared PNC adequacy/utilization to some maternal 22 characteristics. Despite the research supporting improved neonatal outcomes with adequate PNC, many women still do not obtain adequate PNC. Alexander and Cornely (1987) found that only 66.3% of women received adequate PNC in their study. Kotelchuck (1994a) identified 68.5% of women as having adequate or better PNC with his APNCU Index. According to the Michigan Department of Public Health (MDPH) 79.9% of women who had live births in 1993 began PNC in the first trimester, and 73.6% received adequate PNC that same year (Michigan Department of Public Health, 1993). There appear to be several factors that affect the utilization of prenatal care. Six demographic characteristics have been repeatedly linked to inadequate PNC. They are age, parity, maternal education, family income, maternal marital status, and race (Alexander & Cornely, 1987; Goldenberg et al., 1992; Kessner et al., 1973). Norbeck and Anderson (1989) found that support provided by the partner and/or the mother was related to improved birth outcomes. While several authors suggest that social support and/or the support network could improve PNC utilization (Aaronson, 1989; Brown & Ryan, 1992; Goldenberg et al., 1992; McClanahan, 1992) there is no research that actually examines the relationship of PNC to the support network. The only real link in the research has been with the presence of a marital or significant other relationship 23 being related to increased PNC utilization (Alexander & Cornely, 1987; Goldenberg et al., 1992; Norbeck & Anderson, 1988). Size of Support Network The component of the size of the support network related to pregnancy in general has not been well addressed in the literature. There has been some discussion of social support and pregnancy, but while social support is assumed to be present to some degree when a person is identified as supportive, a simple numerical discussion of size of the network has not been commonly reported. May (1992) in her study of pregnant adolescents, reported a negative correlation between network size and gestational age at delivery, but postulated that this might have been confounded by teens dropping out of the school. The average network size reported by May was between five and eight. While Norbeck and Anderson (1989), reported the network size of their pregnant sample to be between 5 and 8, and included network size as a component of social support, they do not analyze it as a separate concept. Mercer and Ferketich (1988) in their research examining social support as a predictor of depression and anxiety during pregnancy report a network size of 6 to 8, but do not compare it to PNC utilization. Lantican and Corona (1992) in their study comparing the support networks of Filipino and Mexican- American primigravidas report a network size of 5 to 6, but 24 once again did not consider PNC as a variable. Inherent in the concept of size, is the assumption that with more people there is some element of increased support. In fact, Mercer and Ferketich (1988) did report a significant correlation between network size and perceived and received support, but as previously stated, their dependent variables were anxiety and depression rather than PNC utilization. Composition of Support Network Once again, although many authors report the frequency of relationships (significant other, mother, family, friends, professionals, etc.) included in the support network of the pregnant woman, the variable of composition itself, has not been examined. There seems to be no discussion as to the relevance of diversity, or different kinds of relationships, within the composition of the support network. Collins et al. (1993) found that in low income women, greater network resources were related to higher infant birthweights and more visits to the clinic for prenatal care. Network resources were identified as having one relative living in the area, having one close friend in the area, and living with the baby’s father. This was the study that came closest to examining the variables under consideration, and while a higher score would indicate a more heterogeneous composition than a low score, it did not consider other potential compositions, only the effect of this one specific 25 composition on birth outcomes. It stopped just short of identifying the adequacy of PNC utilization. Several studies (Mercer & Ferketich, 1988; May, 1992; Norbeck & Anderson, 1989; Norbeck et al., 1983) have identified family support as the most common support group during pregnancy. Lee and Grubbs (1993) found 75% of their inadequate care group sought family guidance in self—care behavior before seeking prenatal care, but failed to mention what percentage of the adequate care group exhibited the same behavior. In their adequate care group, 94% reported that family member helped them with self-care behaviors. In the studies where the support of clergy has been mentioned (Mercer & Ferketich, 1988; Norbeck et al., 1983), the numbers of women identifying supportive clergy have been too small to yield much analysis. Neighbors, health care providers, and counselors are other relationships that have been reported as being in the support network. While there is no research that specifically looks at the diversity of the composition of the support network related to PNC utilization, it seems plausible that a diverse network could "balance out" the ill effects created by particular members of a network, and that the healthy behavior of PNC would surface. Critique of the Literature While there is a significant amount of literature about prenatal care and a significant amount of literature regarding social support, there is a gap in the research 26 relating the adequacy of PNC to the concepts of network size and composition. Many more descriptive studies exploring the exact mechanisms through which PNC is affected by the support network will have to be done before a clear understanding of their relationships is understood. Although the information relating to prenatal care is often derived from fairly large studies, using vital statistics, the information pertaining to support networks in pregnancy often comes from relatively small studies. This makes generalizations more difficult. For instance May (1992) had a sample of less than 50. In addition to the small sample size, it was a non probability convenience sample for which there was no comparison group. Mercer and Ferketich’s (1988) sample had 371 women, and while it was a longitudinal comparative study that controlled for race, marital status, parity, and socioeconomic status, PNC was not discussed. In Norbeck and Anderson (1989) there were 208 women, but neither PNC or the support network was presented. Collins et al. (1993) included 129 women in their study, but used a new instrument for which reliability and validity were not reported. More research that explores the relationship between PNC and support networks is needed. The main difficulty with the existing research however, is that relationships have not been identified for the variables under consideration in this study. Relationships can only be extrapolated from studies exploring the 27 variables independently. In the case of the composition of the support network, even more tenuous connections can be made, because it is only aspects of, not the composition itself that is discussed. This study may therefore fill a gap in the literature by examining the relationship between prenatal care adequacy and the size and composition of the support network. Methods Design This study was a secondary analysis of data obtained from a convenience sample from a not for profit prenatal center in a southern Michigan county. The present study was conducted as an ex post facto descriptive design, in which the researcher examined the relationships between the variables. The original study was an evaluation of the center and included prospective surveys and a chart review. As part of the study, women were asked to complete many instruments. mm The sample consisted of 108 women who participated in the original study. Only women from the Center for Healthy Beginnings, a private not for profit organization, were included, because this sample of women was fairly homogenous. This allowed for the control of some extraneous variables. Of these women, only those who identified at least 1 person in their support network were included. The 28 women were primarily in their early twenties, white, single, and multiparous with little education beyond high school. The reimbursement source reported for 91.7% of the sample was either Medicaid or Medicaid pending, implying that the women’s incomes were within 185% of the poverty level. Operational Definitions The variables of this study were network size and composition and adequacy of prenatal care. The variables have been previously conceptually defined. Adequacy of Prenatal Care Four classifications of prenatal care use (based on the APNCU Index, see Kotelchuck, 1994c) were employed to describe adequacy of care. The four categories were Adequate Plus, Adequate, Intermediate, and Inadequate. The Unknown category, or missing data group, was not used in this study. Because it was a smaller study, not using vital statistics, and only Center women were included, it was assumed that the Unknown category would be too small a group to yield much analysis. Consequently, these data were omitted. The calculation yielding the percentage of PNC visits was based on the ratio of recorded visits to expected visits, with the expected number of visits being equal to the ACOG recommended number of PNC visits when adjusted for gestational age at delivery. Recorded PNC visits were defined as visits that were recorded on the Center records. 29 Gestational age was determined based on the estimated date of confinement (EDC), and was recorded on the Center's records. Initially, data were classified in the PNC Initiation Category (see Table 4) and placed into Adequate or Inadequate groups based on the month of initiation of PNC. Secondly, they were assigned to Adequate Plus, Adequate, Intermediate, or Inadequate groups in the PNC Received Services Category based on the percentage of PNC visits when compared to the recommended number of visits adjusted for gestational age at delivery. The Summary Index Category was then determined by combining these two separate classifications into one. Adegpate Plus Care. Adequate Plus care was defined as care beginning in month 1, 2, 3, or 4 of the pregnancy and exceeding the recommended number of visits by 110% or more. Adeguate Care. Adequate care was defined as care beginning in months 1, 2, 3 or 4 of a pregnancy, and meeting 80-109% of the recommended number of visits based on gestational age at delivery. Intermediate Care. Intermediate care was defined as care initiated before the end of the fourth month of pregnancy and meeting 50—79% of the recommended number of visits. Inadequate Care. Inadequate care was defined as initiation of care after the fourth month and/or meeting less than 50% of the recommended number of visits. 30 Table 4 Summarvadequacv of PNC Utilization Index Based on PNC Initiation and Received Services PNC Received Summary PNC Initiation Services Index Category Category Category Adequate Adequate Plus Adequate Plus Adequate Adequate Adequate Adequate Intermediate Intermediate Adequate Inadequate Inadequate Adequate Adequate Plus Adequate Plus Adequate Adequate Adequate Adequate Intermediate Intermediate Adequate Inadequate Inadequate Intermediate Adequate Plus Inadequate Intermediate Adequate Inadequate Intermediate Intermediate Inadequate Intermediate Inadequate Inadequate Inadequate Adequate Plus Inadequate Inadequate Adequate Inadequate Inadequate Intermediate Inadequate Inadequate Inadequate Inadequate Note. Table from Adeguacy of Prenatal Care Utilization Index: Technical Details and Rationale, by Kotelchuck, M., 1994b. Unpublished manuscript, University of North Carolina at Chapel Hill. 31 Size of Support Network The size of the support network was defined as the total number of individuals listed on the Norbeck Social Support Questionnaire (NSSQ) in response to the instructions of, "list each significant person in your life on the right. Consider all the persons who provide personal support for you or who are important to you now." (Norbeck, et al., 1981) (see Appendix C). There is space for up to 24 network members to be listed on the first half page of the questionnaire, the total number of network members listed reflected the size of the network. Low numbered group. The low group included those listing seven members or less. High numbered group. The high group was defined as networks including eight or more members. Composition of Support Network The composition of the support network was defined by the categories listed by the respondent on the second half page of the NSSQ (see Appendix C). There are nine categories presented in the instructions to be used to identify the relationship of the persons to the respondent. The nine categories are: spouse or partner; family or relatives; friends; work or school associates; neighbors; health care providers; counselor or therapist; minister/priest/rabbi, and other. For the purposes of this analysis however, these nine categories were collapsed into four: family, friends 32 and neighbors, professionals, and others. Family was defined as including spouse or partner, and other family relationships. Friends and neighbors were collapsed into one category, due to these relationships having no other common denominator with other categories. Professionals included the categories of health care providers, counselor or therapist, and minister/priest/rabbi. Because these three categories, all contain some sort of professional relationship, and have been shown in the literature to yield low numbers, they will be collapsed into one category, that of professionals. Others were defined as school/work associates and others. Heteroqeneous composition. Heterogeneous composition was defined as more than one category of relationships. Homoqenous composition. Homogenous composition was defined as only one category of relationships identified. Data from the previously defined high and low groups were then combined with the previously defined homogenous and heterogeneous groups to make four additional groups. These groups were: (a) High numberZHeterogeneous, (b) High numberZHomogenous,(c) Low numberZHeterogeneous, and (d) Low number/Homoqenous. Instrument The NSSQ was developed to be self-administered by Norbeck et al., (1981) to measure various indicators of social support; the support network is one of those indicators. It 33 asks the respondents to list the people in their lives who support them, to classify them according to nine categories, and then to answer questions about them (see Appendix C). For this study only the components of "number in the network" (Questions 5—6) and "relationship" (Questions 34- 53) which identifies the specific category in which a support person is placed by the respondent (Norbeck et al., 1981) were used. Reliability of the NSSQ has been previously established for network property items, although it should be noted that this included items such as duration of relationships and frequency of contact, as well as network size. The "source of support" category, referred to as composition of the network in this study, did not have reliability reported for it. Test- retest reliability for network size was found to be .85 to .92 at one week (Norbeck et al., 1981) and .58 to .78 at seven months (Norbeck, Lindsey et al., 1983). It was felt that the difference had more to do with true changes in the network rather than with reliability issues. Validity for network components specifically were not reported. Data Analysis The data were analyzed using the SPSS, a statistical software package, to report the frequency and percentage for each variable and the demographics of age, education level, marital status, parity, race, and insurance. For question number one, a 2 X 4 contingency table was constructed using 34 the two network size groups: 1 -7, the low numbered group and 8-24, the high numbered group and the four adequacy of care groups. The chi-square statistic was used to test if the proportion of women in the different adequacy of care patterns were statistically different for women with high or low numbers of people in their support network. Similar statistical analysis was used for question number two using instead a 2 X 4 contingency table to include the two homogenous and heterogeneous composition groups and the four adequacy of care groups. For question number three, the same analysis was utilized using a 4 X 4 contingency table with the four composition/size groups: low/homogenous, low/heterogeneous, high/homogenous, and high/heterogeneous cross tabulated with the four adequacy of care groups. The level of significance was set at the 0.05 level. Hpman Subjects Approval Approval to access the data set was obtained from the University Committee On Research Involving Human Subjects (UCRIHS) prior to the access of the data and data analysis (see Appendix A). In the original study informed consent was obtained at the first prenatal visit. The initial study was also approved by UCRIHS (see Appendix B)- This researcher was not provided with any information that would identify the participants directly. Data were reported in aggregate form and were available with identification numbers only. 35 Assumptions and Limitations It was assumed that the initial data were obtained accurately and that the respondents had no reason to answer questions falsely. Secondly, it was assumed that the original data were collected without systematic error. The limitations inherent in these data were mainly related to the non-experimental, non-random, ex post facto design. As with any ex post facto study, the inability to manipulate the variables, the lack of random assignment, and the possibility of incorrectly interpreting the results are weaknesses that were considered. Consequently, there is an inability to determine causality, the most that can be learned from the study is to describe relationships between the variables and to evaluate the strength of those relationships. Additionally, it is understood that limitations exist in the generalizability of the findings. While the women included in the sample were mainly economically disadvantaged, and the results might be generalizable to low socioeconomic groups, they were also mainly white and could not be used to predict relationships for other racial groups. This is true in regard to other factors associated with the homogeneity of the sample as well. Factors such as parity, marital status, and maternal education also limit the generalizability of the findings. 36 Results Sample Description The average age of the 108 women in the sample was 22.88 years (SD = 5.06). The majority had a high school diploma or GED equivalent, were multiparous, and were either single, divorced, or separated. It was primarily a white sample with approximately twenty percent being African/American or Hispanic; no other races were named. Almost ninety-two percent of the sample had either Medicaid or Medicaid pending insurance status. See Table 5 for a summary of the sample characteristics. Results of Analysis for Research Questions For the research variables, the women were divided almost evenly between the small and large support network groups (see Table 6). However, for the composition groups the vast majority were in the heterogeneous group (see Table 6). Consequently, the majority of women were in the high and low heterogeneous groups when the variables were combined (see Table 6). For the PNC groups overall, most of the women received adequate or better PNC (see Table 7). The numbers in the intermediate care group were low resulting in empty cells in the cross tabulation. There were at the most 12 missing cases for any group. Question 1. Are there differences in the adequacy of care patterns among women with hiqh numbers of people in their support network and those with few or none in their 37 Table 5 Sample Characteristics Characteristics Np; % Maternal age 10-19 30 27.8 20-29 64 59.3 30 and above 14 13.0 Educational level r 2:60»... OCmmjozzzxm 2.95am. hMLDx—hh DSMHdOZM 02 HIE Pa 0m ammomm .313»??? p.23 :2 2n... «£3222 62.3: 5 <9: :3 O: 3... any”. nausea. u: :3 330:. (:0 e313 0233». 330: «De <0: 0. (so p; 360293 3 OF can on? 2.: 333 O. 331?»: 53 3333 :5 332032? 3 5 5102955 356.? missus” 2.: 22.3 2 .25: waraoazu _. r>>p4 I... “3.02.0 N. (mom .mfladn mm s. $.11. 26 .2mfl a. UPS “Nam 20 m. (INT. iN . zmr’an/zWOImuI 29 can So 3:913» :2 8 was <0: 93x on 50 noon; .3332: 8 «6:. 5a :2 3 32:. 6320 8 you? 5 <9: 93. t 30:3 2 3232 t 93.? 33526 0.. 3:33 i 33% t to} ea 3.60. 33.53“ t 35303 I 32:: 23 Reina: t 3.53.2 O« 2533: I 33.223102}qu I 032 Network Data