H". ‘ . . ‘ ‘P"Mu_t I "in! '1' ._ _ .‘n‘! ‘5 (l) llllllllllllHlHllHHll 301707 4323 This is to certify that the thesis entitled ADEQUACY 0F PRENATAL CARE FOR LOW INCOME WOMEN WITH EXTENDED TRAVEL IN RURAL SETTINGS presented by Terri Lee Glenn has been accepted towards fulfillment of the requirements for Master of Science degree in NursintL . V, 4 ./ J“ a?!" (4125/4 D] - Ufl-(,.‘7_,« Major professor Date 51/3/43 0—7639 MS U i: an Affirmative Action/Equal Opportunity Institution ‘ LIBRARY i Michigan State E University PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINE return on or before date due. | DATE DUE DATE DUE DATE DUE It'g‘r .02 ISQL 1M chanpfi-p.“ ADEQUACY 0F PRENATAL CARE FOR LOW INCOME WOMEN WITH EXTENDED TRAVEL IN RURAL SETTINGS BY Terri Lee Glenn A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1998 ABSTRACT ADEQUACY OF PRENATAL CARE FOR LOW INCOME WOMEN WITH EXTENDED TRAVEL IN RURAL SETTINGS BY Terri Lee Glenn Access to prenatal care in rural areas has diminished in recent years, requiring pregnant women to travel extended distances to receive third trimester prenatal care and to access hospitals which offer obstetrical services. Adequate prenatal care has been associated with positive birth outcomes. This secondary analysis compared rural low income women who had extended travel to receive prenatal care with rural low income women who had little or no travel to determine if there was a difference in their ability to receive adequate prenatal care. The sample consisted of 55 rural low income women in a small rural county in Michigan. Although findings did not reveal a statistically significant difference in the adequacy of prenatal care between the two groups, there was a higher percentage of women with extended travel who received less than adequate prenatal care. Findings did reveal that over half of the rural low income women with extended travel received less than adequate prenatal care, and over a third of the women who had little or no travel received less than adequate prenatal care. Advanced practice nurses can use these findings to better provide and plan prenatal care services for all rural low income pregnant women. Copyright by TERRI LEE GLENN 199 8 DEDICATION This study is lovingly dedicated to my husband, Jim, my children, Barbi, Joe, and David, my parents, Edward and Barbara Clauss. iv ACKNOWLEDGMENTS This author gratefully acknowledges the assistance of Mildred A. Omar, RNC, PhD. Her patience, support, and encouragement in producing this project, under very demanding and difficult circumstances, will never be forgotten and will forever be appreciated. Gratitude also to Patricia Peek, RN, MS, CS, PNP, for her never ending support and belief in my abilities to see this through to the end, as well as being a valued member of my thesis committee. Appreciation is also extended to Rachel Schiffman, RN, PhD for her assistance and guidance as a supportive and valued committee member and to Yealin Lin who assisted with statistical analyses under demanding deadlines. This author wishes also to strongly acknowledge the support and loving encouragement from family and colleagues who patiently supported her through this entire project, and without whom it could not have been possible. Particular gratitude to Joe Glenn who patiently provided computer assistance and graphics and Kay Conklin who unselfishly provided time and understanding while never losing faith. Loving appreciation to my husband, Jim Glenn, who supported and assisted in every way possible. V TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . . LIST OF FIGURES . . . . . . . . . . . . INTRODUCTION . . . . . . . . Background of the Problem . . . . STATEMENT OF THE PROBLEM . . . . . . . Research Question . . . . . . . Importance of the Study . . . . . THEORETICAL FRAMEWORK . . . . . . . . . Conceptual Definition of Variables Extended Travel for Prenatal Care Adequacy of Prenatal Care . . . . CONCEPTUAL FRAMEWORK . . . . . . . . . REVIEW OF LITERATURE . . . . . . . . Extended Rural Travel for Prenatal Care Adequacy of Prenatal Care for Rural Low Income Pregnant Women . . . . . . . . . Summary and Critique of the Literature METHODS . . . . . . . . . . . . . . . . Research Design . . . . . . . . . Sample . . . . . . . . . . . . . . Setting . . . . . . . . . Operational Definition of the Variables and Instrumentation . . . . . . . . . Adequacy of Prenatal Care . . . . Data Analysis . . . . . . . . . . Research Question . . . . . . . . Protection of Human Subjects . . . Research Assumptions . . . . . . . Research Limitations . . . . . . RESULTS . . . . . . . . . . . . . . . . Description of Sample . . . . . . Analysis of Research Question vi viii ix Hid \lUIU'IU'I Ul-bu 11 19 22 23 25 25 26 26 26 27 29 30 30 31 31 32 32 34 DISCUSSION . Sample . TABLE OF CONTENTS (cont.) Discussion of Results with the Conceptual Framework Implications for Advanced Practice Nursing in Primary Care . . . . . . . . . . . . Recommendations for Further Research . . . . . SUMMARY . . . LIST OF REFERENCES . . . . . . . . APPENDICES Appendix Appendix Procedure for Data Collection . . Maternal Self-Report Health and Prenatal Care Utilization Survey . 36 36 43 45 49 50 52 56 58 Appendix C: Mother's Hospital Chart Record Review . . . . . . . . . . . . . . . . . Appendix D: Patient Satisfaction with Prenatal Care Survey . . . . . . . . . . . . . . . . . Appendix E: UCRIHS Approval . . . . . . . . . . . . vii LI ST OF TABLES Table 1: Frequencies of Sample Demographic Variables by Distance Traveled . . . . . . . . . . . . . 33 Table 2: Adequacy of Prenatal Care Indices (four categories) by Distance Traveled . . . . . . . 35 Table 3: Adequacy of Prenatal Care Indices (two categories) by Distance Traveled . . . . . . . 35 viii LIST OF FIGURES Figure 1: Starfield Model: A Basis for Evaluating Primary Care . . . . . . . . . . . . . . . . 13 Figure 2: An Adapted Conceptual Framework for Evaluating Adequacy of Prenatal Care From Starfield's Model: A Basis for Evaluating Primary Care . . . . . . . . . . . . . . . . . . . . 15 ix INTRODUCTION BiQKQIand_Q£_Ih§_EIthfim Access to early and consistent prenatal care has continued to be the leading strategy in reducing infant mortality (York, Grant, Gibeau, Beecham, & Kessler, 1996). The quality of life for infants and children is often dependent on the adequacy of the prenatal care that is received by pregnant women (Leatherman, Blackburn, & Davidhizar, 1990). Adequate prenatal care is associated with positive pregnancy outcomes, including increased birth weights, decreased numbers of preterm deliveries, and decreased infant mortality. For these reasons adequate prenatal care is an American health priority (Healthy People 2000 (USDHHS), 1990; Johnson, Primas, & Coe, 1994; KIDS COUNT in Michigan, 1995; Raine, Powell, & Krohn, 1994). Rural residency, however, often poses a barrier towards achieving this priority. Rural women often receive less than adequate prenatal care (York et a1., 1996). Rural women must often travel great distances to access prenatal care. Identification of the impact of extended travel on prenatal care utilization could assist policy planners in the design and delivery of prenatal care services for rural women to achieve the goal of adequate prenatal care. The 1 2 purpose of this study was to describe the nature of the association between extended travel by rural low income pregnant women and their adequacy of prenatal care utilization. While the association between adequate prenatal care and positive outcomes has been established, there still exists a need to determine factors and conditions which influence a pregnant woman's decision to initiate and continue prenatal care (Goldberg, Patterson, & Freese, 1992). Several sociodemographic characteristics have been associated with the failure to obtain prenatal care. "Healthy People 2000" (USDHHS, 1990) indicates that low income women lack comprehensive prenatal care. Rural residency has also been associated with failure to obtain adequate care for some women (Nesbitt, Connell, Hart, & Rosenblatt, 1990). Many rural hospitals have closed in recent years and rural health care providers have ceased to provide obstetrical care complicating access to prenatal care for rural women (Fossett, Perloff, Kletke, & Peterson, 1991). Thus, rural residents must often travel extended distances to access health care. In a small rural county in lower Northern Michigan statistics reveal that there is limited prenatal care available. Pregnant women in this rural community often must travel more that 30 miles one way to access adequate prenatal care. Recognizing that health care providers who provide prenatal care to rural women are limited directs 3 attention to options in solving this problem. To decrease the distance traveled to access prenatal care, advance practice nurses (APNs) working in a collaborative practice with a physician who provides obstetrical care can be an option recognized as a solution to this problem. The purpose of this study was to investigate if there was an association between extended travel and the adequacy of prenatal care received by a group of rural low income women. Identification of extended travel as a barrier which interferes with the ability to receive adequate prenatal care will help target interventions and improve prenatal care for rural women. Statement of the Problem Research supports the fact that rural women have decreased access to prenatal care (Bushy, 1990; McClanahan, 1992). McDonald and Coburn (1988) found that even when variables such as income, insurance, and education were controlled, living in rural settings was a significant predictor of adequacy of prenatal care, such that rural women often had less than adequate prenatal care (McDonald & Coburn, 1988). In the most recent data available for a small rural county in Northern Michigan it was reported that from 1990- 1992 nearly 41% of the pregnant women received less than adequate prenatal care (Michigan Department of Public Health [MDPH], 1992). Hospital obstetrical inpatient services within this county have not been available to residents 4 since 1986. Continuous prenatal care and delivery are unavailable to pregnant women of this county. If women receive prenatal care from local prenatal care providers they must transfer to another prenatal care provider in the third trimester of pregnancy and deliver in a neighboring county. Minimum travel is greater than 30 miles one way to receive third trimester care and to access a hospital which provides obstetrical care. With extended travel the potential problems of lost time from work, the need for and cost of travel, and securing reliable transportation exist. None of the obstetricians in the neighboring counties offer evening or weekend hours. It has been reported that women who do not receive adequate prenatal care report increased problems with transportation in comparison to the clients who received adequate prenatal care (Sable, Stockbauer, Schramm, & Land, 1990). Current literature does not identify the barrier of “extended travel" to determine if this creates an access problem, and, therefore, decreases the number of pregnant low income rural women who receive adequate prenatal care. This study examined extended travel for prenatal care by rural low income pregnant women and if this was associated with adequacy of prenatal care. 82W Is there a difference in adequacy of prenatal care for rural low income pregnant women who have extended travel and those who have little or no travel? W It is critical that adequate prenatal care be a priority for rural low income pregnant women. The extended distance traveled to receive adequate care needs to be studied to determine if it is a barrier for rural low income pregnant women in initiating and completing adequate prenatal care and to determine whether alternatives may be introduced to improve utilization of prenatal care for low income pregnant women in rural areas. If extended travel is identified as a barrier to receiving adequate prenatal care, the advanced practice nurse (APN) working with prenatal clients may use this information to help problem solve ways to enhance prenatal care attendance, as well as being a client advocate to promote alternative delivery of prenatal care services which address the issue of extended travel for low income rural women. Theoretical Framework 2 l J E E' 'l' E M . I] This section begins with the conceptual definitions of the variables, extended travel for prenatal care and adequacy of prenatal care, as they are defined in the existing literature. Next, the variables have been incorporated into Starfield's model of the health service system (1992). W Travel to access prenatal care has been described in the literature as a barrier to receiving adequate prenatal 6 care (Johnson et al., 1994; Leatherman et al., 1990; McClanahan, 1992). Transportation problems can involve lack of public transportation, lack of access to a reliable vehicle, lack of funds to fuel the vehicle, and lack of an available licensed driver. All of these problems are compounded when the distance traveled is extended. Other factors associated with extended travel for prenatal care are rural residency, low socioeconomic status, and limited available obstetrical care (Hangsleben, Jones, Lia-Hoagberg, Skovholt, & Wingeier, 1995; Johnson, et al., 1994; McClanahan, 1992). McGuirk and Porell (1984) described travel time in terms of distance traveled and time spent traveling. When distance traveled is extended, the amount of time it takes to access care is increased, as well as the amount of time needed off from work. Time off from work often results in loss of pay or accrued leave time (Omar & Schiffman, 1995). In the literature when travel has been cited as a barrier to prenatal care, the distance involved in the travel has not been well defined. Travel alone is a barrier, but whether extended travel has a greater effect on the client's ability to access or receive prenatal care is unclear, since the definition of travel is unclear. A geographical barrier can refer to the adequacy of transportation of a client or the distance to be covered to receive care (Starfield, 1992). Extended travel for rural residents includes more than mileage and time. In a small 7 rural county in lower Northern Michigan where extended travel is necessary to access prenatal care, particularly in the third trimester and for delivery, mileage one way is greater than 30 miles. To travel this distance in ideal conditions requires a minimum of two hours travel time, which does not include time with the provider. Rural geography is generally far from the ideal of four lane highways. Rural residents are required to travel two lane roads which are difficult to travel even in good weather. Northern Michigan, as in many rural areas, experience adverse weather conditions throughout the year. Rain, sleet, and snow can potentially have an adverse effect on a pregnant woman's ability to travel extended distances in rural terrain. For this study extended travel is defined as a geographical barrier for access to prenatal care. W The health care that a woman receives throughout her entire pregnancy, which is referred to as prenatal care, has been recognized as important since the early 1900's (McClanahan, 1992). Prenatal care has been identified as a measure of health system utilization and considered an indicator of access to health care in general. Prenatal care can have the most positive effect on birth outcomes when it is initiated early and continues for the duration of the pregnancy (KIDS COUNT, 1995). Adequate prenatal care has been associated with positive pregnancy outcomes (McDonald & Coburn, 1988; Meikle, Orleans, Leff, Shain, & 8 Gibbs, 1995; Sable et al., 1990). Less than adequate prenatal care has been linked with an increased incidence of low birth weigh infants, which is a major contributor to infant mortality and morbidity (Leatherman et al., 1990; Sable et al., 1990). Defining adequacy of prenatal care in the literature is generally based on the initiation of care and the total number of visits during the entire pregnancy. Prenatal care has both qualitative and quantitative aspects. Qualitative aspects of prenatal care, which refer to the content of the care during the prenatal visit, are difficult to measure. The quality of the prenatal care, such as skill of provider or type of care offered during the prenatal visits, is not generally measured in studies, even though it could potentially influence the outcome of care. The literature provides different definitions for “adequate prenatal care," generally from a quantitative perspective. McClanahan (1992) defined adequacy of care, quantitatively, as beginning in the first trimester and continuing on a regular basis every four weeks until 28 weeks, then every 2 weeks until 36 weeks, and weekly thereafter. The Kessner Index has been used extensively for defining adequacy of prenatal care (Katz, Armstrong, & LoGerfo 1994; KIDS COUNT in Michigan, 1995; McDonald & Coburn, 1988). According to the Kessner Index, adequate prenatal care is care which begins within the first trimester and includes an average of at least one or two 9 additional prenatal visits per month of gestation, depending on the length of gestation. The Kessner Index is based on the quantitative model and is associated with favorable birth outcomes. Others have noted, however, great variation in the number of visits recommended for prenatal care in different parts of the world with positive birth outcomes even with very different schedules of prenatal visits, including less prenatal visits for low risk women (McDuffie, Beck, Bischoff, Cross, & Orleans, 1996). Thus, there does not seem to be a universal definition used for defining “adequate prenatal care". Several other measures have been utilized to measure adequacy of prenatal care. Alexander and Cornely (1987) and Kotelchuck (1994a) devised utilization indexes which have been widely used and which are based on the American College of Obstetrics and Gynecology (ACOG) standard of care. The American College of Obstetricians and Gynecologists has endorsed a set of 14 prenatal visits for low risk women who present in the first trimester as adequate prenatal care (American Academy of Pediatrics [AAP], 1992). Providers of prenatal care generally adhere to ACOG standards for prenatal care (Sable et al., 1990). Kotelchuck (1994c) revised the Kessner Index for prenatal care utilization for the following reasons. Kotelchuck cited four features which he believed did not accurately capture the number of women receiving adequate prenatal care when measured according to the Kessner Index. 10 The first factor was that the Kessner Index was principally a measure of when prenatal care was initiated, and secondly, that the Kessner Index did not distinguish less than adequate care due to late initiation, from less than adequate care due to an insufficient number of visits. Kotelchuck also noted that to accurately capture the numbers of clients with adequate prenatal care, one must make distinctions between normal term pregnancies and postterm pregnancies. The Kessner Index did not go beyond 40 weeks gestation. In addition, the Kessner Index did not allow for unknown categories lacking documentation for missing data, such as gestational age, missed visits, and missing initiation dates (Kotelchuck, 1994c). Kotelchuck revised Kessner's Index to more accurately reflect prenatal care utilization. For prenatal care to be considered adequate, using Kotelchuck's (1994a) “Adequacy of Prenatal Care Utilization Index", prenatal care must include the following components. First, prenatal care must be initiated early in the pregnancy. If a woman does not seek or access prenatal care prior to her fourth month of pregnancy, then her prenatal care is not adequate. The earlier prenatal care is initiated the more adequate the care is. Continuity of care is equally as important as initiation of care, according to Kotelchuck (1994c). For prenatal care to be adequate one must also consider the number of visits (based on gestational age) received during the time the woman is in prenatal care. Adequate care cannot be provided if a woman 11 is for any reason unable to be physically present at her prenatal care visits. For prenatal care to be adequate, therefore, it must be not only be initiated early in the pregnancy, but an adequate number of recommended visits, based on ACOG standards, must also be received. Kotelchuck's Index does not address the qualitative aspects or content of the prenatal care visits. For this study, adequacy of prenatal care is defined as care which is initiated early and is continuous throughout the pregnancy, as opposed to less than adequate prenatal care which is care that is initiated late and is discontinuous or not received consistently throughout the pregnancy. Conceptual Framework The conceptual framework utilized in this study was an adaptation of the Starfield Model (1992) of the health services system. The Starfield Model was developed to explain how the outcomes of a health care system are affected by the interaction of the physical and social environment, the process and the structure. The determination of client outcomes in terms of a health care system involves analyzing the structure and process components (Starfield, 1992). The assumption in Starfield's model which pertains to this study is a client's ability to achieve adequate care may be more than behavioral characteristics that are culturally or socially determined. The problem may be complex and as primary care providers it is necessary to determine if factors in the health care 12 service system affect the acquisition of adequate care (Starfield, 1992). The main variables of Starfield's Model are structure, process, outcome, and the effect of the social and physical environment on these variables (Figure 1). It is the interaction of these variables which determines whether the desired health status or outcome will be achieved. Determinants of health are the genetic structure of an individual which is heavily influenced by cultural or social behaviors, the social and physical environment, and the nature of the health care provided. Starfield's model (Figure 1) includes ten sub-elements under structure, which refer primarily to the health care structure. Structure is the resources needed to provide services and the components of structure according to Starfield are: personnel, facilities and equipment, range of services, organization, management and amenities, continuity, accessibility, financing, population eligible, and governance. Centered under process of Starfield's model is “persons," which identifies a direct, reciprocal effect on the “person" by the structure as well as by the social and physical environments. The process is twofold. Process begins with the provision of care by the provider, which involves recognition of the problem, diagnosis, management, and reassessment. Secondly, the process requires the receipt of care by the client. Involved in the receipt of 13 The Health Care System Personnel Facilities and equipment Range of services STRUCTURE Organization ' . Management and amenities ‘1 Continuity Accessibility Financing Population eligible I Problem recognition Diagnosis Management L Reassessment ‘ __________ _ Social — r- ‘I ‘— PROCESS PERSONS 4—» and |_ _: _. _ __ —1 physical Utilization environment Acceptance and satisfaction Understanding Participation Provision of care Receipt K of care OUTCOME Achievement ' 3; Resilience Figure 1. Starfield Model. A Basis for Evaluating Primary care (Starfield, B., 1992). l4 care is utilization, acceptance/satisfaction, understanding, and participation in care provided by health care system (Starfield, 1992). The third component of Starfield's model is outcome. The structure of the health care system, the social and physical environments of the individual, its effect on the processes of care and its impact on the health status of the client produces an effect, known as outcome of care. Starfield's conceptualization of outcome of care is defined in seven components: longevity, activity, comfort, perceived well-being, disease, achievement, and resilience (Starfield, 1992). All components are viewed longitudinally and some aspect of each component should be assessed when determining the effectiveness of a health care system. All three components, according to the model, are affected by the social and physical environments of the client. The social and physical environments include elements within the society which may be modifying factors, such as superstitions and fears, natural disasters, socioeconomic factors, as well as values and beliefs. In the prenatal care delivery system, structure consists of the resources needed to provide prenatal care and is the mechanism for which continuity of prenatal care is provided. To measure attainment of prenatal care, according to Starfield, one must consider several structural elements including accessibility (Figure 2). Starfield recognizes that in health care there are different aspects 15 The Health Care System ¢ Structure Extended Rural Travel (Accessibility) Social & Physical Environment @ral Low-Income Pregnant Women Rural Process Utilization ¢ P Low-Income Adequacy of Prenatal Care — Outcome Pregnancy Outcomes f Figure 2. An adapted conceptual framework for evaluating adequacy of prenatal care. From Starfield's Model: A Basis for Evaluating Primary Care (Starfield, 1992), p. 13). 16 of accessibility, including time, geographical accessibility (adequacy of transportation and distance to be covered), as well as psychosocial accessibility. In this study, the variable “extended travel" falls under accessibility (geographical), which is the distance a client needs to travel to access prenatal care (Starfield, 1992). To receive prenatal care in rural areas often requires traveling extended distances. Rural being defined as “sparsely populated" has an inherit problem of access to health care (Horner et al., 1994). Health care services are generally located where the largest number of clients can access care. The scope of services is also generally in proportion to the demand leaving rural residents the burden of traveling greater distances to access care. Health care services must be financially responsible, therefore, rural residents are affected by their social and physical environment and the socioeconomic factors which limit the amount of services that can be offered them. Health care services which are often limited include, lack of available obstetrical providers within the local community and lack of obstetrical facilities within the county (Hangsleben et al., 1995; McClanahan, 1992; Schaffer & Lia-Hoagberg, 1994). Other barriers to access which occur due to extended travel, include cost for transportation (gas, auto maintenance), access to reliable vehicles, loss of wages and child care costs (Johnson et al., 1994; Sable et al., 1990). 17 The status of the structure of resources of the prenatal care system directly impacts the process of prenatal care. Process refers to the obtaining of prenatal care by the client or "person" (Figure 2). The structure is the mechanism which provides the prenatal care, but for that care to be processed the client must utilize the services provided. Utilization of services is the necessary process for achievement of the desired outcome. It is well documented that outcomes of pregnancy are positively influenced by the utilization of prenatal care services. Utilization of prenatal care is necessary for the client to achieve adequate prenatal care. If travel is extensive and the barriers associated with extended travel do not allow the client to process, or utilize prenatal care, then adequate prenatal care may be difficult to achieve. Structure and process may be affected by the modifying factors related to the social and physical environment of rural low income populations. Extended travel for obstetrical services, low socioeconomic status, as well as the health care behaviors and beliefs of rural populations, may directly or indirectly serve as barriers that affect their ability to utilize and ultimately receive adequate prenatal care. According to Starfield, health research needs to progress to a point where it can more adequately explore the association between the structures and the processes of health service systems, to determine their effect on 18 patient outcomes (1992). Outcomes serve as the criteria against which to judge the success or failure of these services. It was the intent of this study to investigate the association between extended travel for low income rural women for prenatal care (structure) and their ability to obtain adequate care (process), in an effort to improve outcomes. Review of Literature A review of available literature revealed no studies where the study variables, extended travel and adequacy of prenatal care for rural low income women were associated. Travel for prenatal care was generally listed in the literature under structural or sociodemographic barriers to accessing prenatal care and was included in studies which explored multiple variables in relation to receiving adequate prenatal care (Goldberg et al., 1992; Johnson et al., 1994; Joyce, Diffenbacher, Greene, & Sorokin, 1984; Leatherman et al., 1990; Lieber, 1994; McClanahan, 1992; Schaffer & Lia-Hoagberg, 1994). In regards to adequate prenatal care, the majority of studies done over several decades report that adequate prenatal care is associated with increased positive pregnancy outcomes. The definitions for adequate prenatal care in reviewed studies were often found to be inconsistent (Goldberg et al., 1992; Johnson et al., 1994; Joyce et al., 1984; KIDS COUNT in Michigan, 1995; Schaffer & Lia-Hoagberg, 1994; York et. al., 1996 ). Studies which researched the l9 ability to receive adequate prenatal care for rural low income pregnant women were limited and no research could be found which studied the effects of extended travel for rural low income pregnant women and their ability to receive adequate prenatal care. The review of literature will describe extended travel for prenatal care for rural populations. Next, adequacy of prenatal care for rural populations is presented. Wm Traveling for health care has been and continues to be a major concern for recipients of care (Dutton, 1986; Horner et al., 1994). McClanahan (1992) explored barriers women had accessing prenatal care in an effort to identify ways that nurses could influence these barriers. The author, in a literature review, reported that a rural residency can affect the use of prenatal care. Rural populations are potentially predisposed to risk factors such as low socioeconomic status and limited obstetrical care. An additional barrier imposed by rural residency can be the "great distances" to travel to access health care providers. Johnson et al. (1994) conducted a small retrospective study (n=15) to explore the reasons given by rural women who had delivered without prenatal care as to why they had not initiated prenatal care. Eleven barriers were identified. One of the most common barriers identified was transportation. Respondents reported not having reliable transportation, money for gasoline, or maintenance of the 20 vehicle as barriers to accessing prenatal care. The authors did not relate the barrier of transportation to women as to whether they traveled or did not travel. The reader is left with the implication that travel is involved, due to the sample being of rural residency. Fossett et al. (1991) reported similar findings. The authors examined the availability of office-based prenatal care to Medicaid patients in Illinois, due to a concern over Medicaid eligible clients being able to access prenatal care in rural areas with the decrease in rural prenatal care providers. The authors found that transportation ranked second only to finances as a barrier to receiving prenatal care for rural low income women and that clients preferred to limit their travel time and sought care from local physicians rather from those located farther away. Sable et al. (1990) interviewed retrospectively, 1,484 urban and rural, primarily low income, women in Missouri to determine barriers to receiving adequate prenatal care. Women who received less than adequate prenatal care reported increased problems with transportation as compared to the women who received adequate prenatal care. Distance traveled, however, was not identified. Bronstein and Morrisey (1990) studied obstetrical care and rural travel. This longitudinal study covered two time periods five years apart and explored the travel patterns of 1,689 pregnant women at time 1 and 1,500 pregnant women, time 2, living in rural Alabama. Women traveled up to 80 21 miles one way to access obstetrical care, with the mean distance traveled by the rural women in the study being 23 miles. This study did not address whether miles traveled directly affected a woman's ability to access adequate obstetrical care, but focused on the patterns rural pregnant women traveled for inpatient obstetrical care. The authors stated that women were in support of increased travel if the quality of obstetrical services was superior at a larger hospital than that of the small rural hospital. Distance traveled was assoated with the size of the hospital and neonatal intensive care services. Women traveled greater distances to access larger hospitals and hospitals which had neonatal intensive care units. The study did not report women who did not initiate prenatal care or whether the care received was adequate. Horner et al. (1994) conducted the most recent study found which explored the factors which affect health care in regards to travel for rural residents. This descriptive study consisted of 19 subjects who lived outside a 10 mile radius of a 100 bed hospital located in a rural area of Southern Georgia. This study reported that 31% of rural dwellers did not travel beyond their home town for health care. Travel for health care imposed added problems for those seeking health care. It was reported that the participants would access fldistant-care" if the health problem was perceived as serious. The distance that people were willing to travel was directly related to the extent to 22 which they perceived the problem as serious. According to this study, as the distance required for travel increased so did the problem of transportation. Health care in general was the focus of this study, however, not specifically prenatal care. ;.-.|. .‘~-... .- 0 Hanan Statistics target rural dwelling as an at risk population for not receiving adequate prenatal care. York et al. (1996) found that the adequacy of prenatal care depended on geographic residence. Women who reside in isolated rural areas generally did not receive adequate prenatal care. Nesbitt et al. (1990) studied 33 rural counties in the state of Washington. The researchers found an association between access to prenatal care and distance traveled by rural women for prenatal care. Rural women who traveled outside their communities for prenatal care had higher percentages of complicated deliveries and increased numbers of premature births. According to several studies, low income pregnant women have been reported to be statistically more at risk for receiving less than adequate prenatal care (Johnson et al., 1994; Meikle et al., 1995; Sable et al., 1990). Johnson et al. (1994) conducted a small study (n=15) which included women who delivered without prenatal care. These low income women by inclusion all received inadequate prenatal care. 23 Sable et al. (1990) conducted a study to identify barriers to prenatal care of both rural and urban postpartum women, to see if barriers differentiated between adequate and inadequate prenatal care. To be considered inadequate prenatal care in this study care was initiated after the fourth month of pregnancy and by the number of visits received after prenatal care was initiated (based on ACOG recommendations). The researchers in this study interviewed a large number (n=1,484) of postpartum women and found that transportation and being of low income were two barriers identified by the women who received inadequate prenatal care as compared to the women who received adequate prenatal care. 5 i 2 'l' E ll Ii! l A literature review revealed a very limited number of studies which explored or supported the association between extended travel and a rural woman's ability to receive adequate prenatal care. There were a multitude of factors identified which affected a woman's ability to access adequate prenatal care. The literature addressed rural and low income as barriers to receiving adequate prenatal care, however, current studies did not clearly relate to what extent travel or extended travel impacted these two variables (Horner et al., 1994; Johnson et al., 1994; McClanahan, 1992; Nesbitt et al., 1990; Sable et al., 1990; York et al., 1996). 24 Samples were often not clearly described in the reviewed studies. Sociodemographic data, such as income and geographical location (rural or urban) were not always clearly reported. Not having access to income or geographical location of the sample (distance required to travel to access prenatal care providers) limited the application of articles included in the literature review (Fossett et al., 1991; Leatherman et al., 1990; Meikle et al., 1995; Sable et al., 1990). Several studies did include sociodemographic information, such as rural dwelling and low income (Johnson et al., 1994; Lieber, 1994). Some studies were qualitative and were limited due to small sample sizes which ranged between 15-50 (Horner et al., 1994; Johnson et al., 1994). Studies which used larger samples, which related to this study, were done retrospectively using health or Medicaid enrollment figures, lacking were large scale, prospective studies. Additional limitations of the studies reviewed were the inconsistent definitions of the variables. In reference to travel, mileage was not reported clearly, if at all. Horner et al. (1994) defined travel as greater than 10 miles. Reference was made toi“far travel” travel in a study by Horner (1994) and “distant care" by McClanahan (1992); however, the variables were not defined by the authors (Horner et al., 1994; McClanahan, 1992). The definition of adequate prenatal care varied with each study. Sable et al. (1990) clearly defined adequate prenatal care, as did 25 McClanahan (1992), although even when the definition was clearly reported the measurements were often different. The results of studies are often very different when measured by different indexes (Kotelchuck, 1994c). Clearly the literature reveals the need for studies which define and isolate variables such as extended travel for rural low income pregnant women and the effect this variable has on women receiving adequate prenatal care. The scant literature highlights that factors which affect a woman's ability to obtain prenatal care have fallen short, often resulting in inadequate prenatal care. Information gained from studying the association between extended travel and adequacy of prenatal care will assist planners of rural prenatal care in enhancing access to prenatal care service for rural low income pregnant women. Methods W This was a descriptive study of adequacy of prenatal care for women who travel extended distances for prenatal care, through a secondary analysis of data collected previously by Omar, Schiffman, and Bauer (1995) from the study, “Barriers, Expectations, and Patient Satisfaction as Predictors of Prenatal Care Utilization and Maternal and Infant Outcomes in a small rural county in Michigan". See Appendix A for data collection procedure of the primary study. 26 83111213 The original sample consisted of 61 of the 62 low income pregnant women who were asked to participate. The participation rate was 98 percent. The sample for this study consisted of 55 women for whom there was complete data available to run analyses for adequacy of prenatal care: 34 who traveled extended distance to receive prenatal care, and 21 women who had little or no travel to receive prenatal care . Setting The small rural county in this study is in lower Northern Michigan and is designated as medically underserved. This county has one county hospital which does not provide obstetrical services and all women must travel out of the county after 28 weeks of gestation for prenatal care and for obstetrical delivery services. This necessitates some women traveling in excess of 100 miles round trip (average 64 miles round trip) to receive prenatal care and delivery services. l l' J E E' 'l' M . l] i I I I !° Extended_Travel_fgr_2nenatal_gaze. Extended travel for prenatal care in this study was measured by Item #7, u .. - . - ‘o o 9 -., . . - ..- ,. -.. -. '0 miles on the Maternal Self-Report Health and Prenatal Care Utilization Survey (Omar & Schiffman, 1994) (Appendix B). The survey is a 16 item instrument designed to assess a woman's utilization of health care services during 27 pregnancy. There is no validity and reliability reported for this tool. Item #7 of the Maternal Self-Report Health and Prenatal Care Utilization Survey asked clients to write name, location and distance (in miles) traveled one way to obtain prenatal care. The answers were hand-written in the spaces provided. For the purpose of this study, travel for prenatal care was operationally defined as either extended travel, or not extended travel, based on the mean distance traveled by all women from the primary study which was equal to, or greater than 32 miles one way. The extended travel group was represented by women who traveled 32 miles or greater (one way) to receive prenatal care. The not extended travel group consisted of women who traveled less than 32 miles one way to receive prenatal care. Distances in excess of 30 miles in rural terrain could be difficult for rural residents to travel. This definition includes travel by mileage only and does not factor in the time involved traveling to and from the prenatal appointment. AQBQNAQ¥_Q£_EI§naLal_£§I£ For the purpose of this study, adequacy of prenatal care was operationally defined quantitatively using the three indices of Kotelchuck's (1994tn “Adequacy of Prenatal Care Utilization Index" which are: a) Adequacy of Initiation of Prenatal Care Index; b) Adequacy of Received Services Index; and c) Summary Adequacy of Prenatal Care Utilization Index. The first index, Adequacy of initiation of prenatal 28 care, is a rating of the adequacy of the timing of initiation of prenatal care. The month of initiation is rated: Adequate plus = months 1 and 2; adequate = months 3 and 4; intermediate = months 5 and 6; and inadequate a months 7-9. The second dimension, Adequacy of received services, rates the adequacy of the number of prenatal care appointments that the woman has had since she initiated care. Adequacy of received care equals the ratio of the number of observed visits to the number of expected visits (adapted to reflect gestational age at initiation of care and at delivery), based on American College of Obstetricians and Gynecologists (1985) standards (as cited in Kotelchuck, 1994b). Four classifications are used to group the adequacy of received care ratios: Adequate plus (110% or more of the expected visits); adequate (80 -109% of expected visits); intermediate (50-79% of expected visits); and inadequate (less than 50% of expected visits). The third index is a summary index which is directly derived from the Initiation of prenatal care and Received services indices. The Summary Index defines adequate plus (intensive) prenatal care as prenatal care initiated by the 4th month and 110% or more of expected visits are received. Adequate care is defined as prenatal care initiated by the 4th month and 80-109% of expected visits are received. Intermediate care is defined as prenatal care initiated by the 4th month and between 50- 79% of expected prenatal care visits are received. Inadequate prenatal care is defined as any prenatal care 29 initiated after the 4th month of pregnancy or if less than 50% of the expected prenatal care visits are received. Data for calculation of "Adequacy of Prenatal Care" were obtained in the primary study from a review of the mother's and infant's hospital records. The following information was obtained: a) week of gestation when the woman first obtained prenatal care; b) total number of prenatal visits for routine assessment; c) month, day, year of delivery; and d) length of gestation in weeks (Appendix C). Wis Data analysis in this study was done using the SPSS/PCT statistical software package. Demographic information was obtained from the Patient Satisfaction with Prenatal Care Instrument (PSPC) developed by Omar and Schiffman (1994) (Appendix D). Only those questions specifically related to demographics were used in this study. These included age, race, total number of times the woman was pregnant (gravidity), level of education, marital status, insurance type, and work status. Descriptive statistics were used to describe the miles traveled one way for prenatal care, and the adequacy of prenatal care. Cross tabulation with chi- square analysis was done on the demographic variables to determine if there were any statistically significant proportional differences between the two groups by distance traveled. 30 W Is there a difference in adequacy of prenatal care for rural low income pregnant women who have extended travel and those who have little or no travel? Three separate 2 x 4 cross tabulations using the chi-square statistic were used for data analysis, one for each of the three APNCU Indices by travel groups. Because of the small sample size, a second set of three cross tabulations using the chi-square statistic was utilized with the three adequacy indices collapsed into two categories (adequate and less than adequate). The “adequate" category included those women who were classified as either Adequate Plus or Adequate according to Kotelchuck's (1994b) APNCU index. Thea'less than adequate” category included those women who were classified as either Intermediate or Inadequate according to Kotelchuck's (1994b) APNCU index. A level of significance established at 0.05 was utilized for all data analyses. W The original study by Omar et al. (1995) was approved by the University Committee on Research Involving Human Subjects (UCRIHS) (Appendix E). The data were entered by identification numbers only and without personal identifiers, so that no link could be made with the name of any participants in this study. The present study used secondary data from the original study and this researcher did not have access to the identities of the participants. 31 Approval was obtained from UCRIHS prior to data utilization for this study (Appendix E). W It was assumed that all of the potential subjects were given an equal opportunity to participate. It was assumed that the subjects were given sufficient explanation so that they were able to understand the Maternal Self-Report Health and Prenatal Care Utilization Survey and honestly answered the questions asked and that the women had the ability to determine quantitatively and record accurately the mileage for prenatal care. Once the data were collected it was assumed that the data were entered accurately. E l I' 'I ll Threats to the external validity of this study are the absence of random sampling and the sample size. This limits the generalizability to the general population; however, it is difficult to sample large number of subjects when studying rural populations, as time and logistics of finding and tracking subjects is difficult. Another limitation was the lack of established parameters for defining extended travel for health care by rural residents. A disadvantage to all current utilization indexes used to measure adequacy of prenatal care is that they are all based on normal, not high risk pregnancy, and for women at risk it would require an adjustment in the number of expected visits, and risk factor adjustment. This study examined the quantitative measurement of prenatal care, not 32 the qualitative aspect of the care; also lacking was a determination as to whether the care received was perceived by the participant as worthy of the effort and travel, to receive all of care needed to be considered adequate prenatal care. Results We This study consisted of 55 women ranging in ages 15 to 41 years. The mean age of the primary study sample was 24 years (SD=5.21). Complete demographic data was available on 57 women from the original sample of which slightly more than three-fifths (61%, n=35) traveled equal to or greater than 32 miles one way to receive prenatal care, and nearly two-fifths (39%, n=22) traveled less than 32 miles one way to receive prenatal care (Table 1). More than four-fifths (86%, n=49) of the study sample was comprised of White/Non- Hispanic women, with (82%, n=47), of the sample having a high school education or greater. Three quarters of the study sample reported being married (n=43) with 95% (n=52) being multigravida. Sixty-four percent (n=37) reported they were receiving Medicaid, yet half of the sample reported working outside the home (Table 1). There were no significant differences on the demographics between the two groups of women, those with extended travel as compared to those that did not travel extended distances for prenatal care . 33 Table 1. ‘0l‘0 ‘ 0 II ‘ D‘ueq .e. e I . £11251). Demographics Travel < 32 mi. Travel 2 32 mi. Total n (‘l n (3) n (‘l Race White (Non-Hispanic) 19 (86) 3O ( 85) 49 (86) Hispanic 1 ( 5) 3 ( 9) 4 ( 7) Native American 2 ( 9) 0 ( 0) 2 ( 4) Other 0 ( O) 2 ( 6) 2 ( 3) Marital Status Single 4 (18) 5 ( 14) 9 (16) Married 17 (77) 26 ( 74) 43 (75) Separated 1 ( 5) 1 ( 3) 2 ( 4) Divorced 0 ( 0) l ( 3) 1 ( 2) Other 0 ( 0) 2 ( 6) 2 ( 3) Educational Level Less than high school 0 ( 0) 1 ( 3) 1 ( 2) Some high school 2 ( 9) 7 ( 20) 9 (16) High school grad ll (50) 12 ( 34) 23 (40) Some college/tech 8 (36) 12 ( 34) 20 (35) College graduate 1 ( 5) 1 ( 3) 2 ( 4) Post college 0 ( 0) 2 ( 6) 2 ( 3) Medicaid Yes 17 (77) 20 ( 57) 37 (65) No 5 (23) 15 ( 43) 20 (35) MICH-Care Yes 2 ( 9) 8 ( 23) 10 (18) No 20 (91) 27 ( 77) 47 (82) Private insurance Yes 10 (46) 9 ( 26) 19 (33) No 12 (54) 26 ( 74) 38 (67) Selfpay Yes 1 ( 4) 0 ( 0) l ( 2) No 21 (96) 35 (100) 56 (98) Work outside home Yes 11 (50) 18 ( 51) 29 (51) No 11 (50) 17 ( 49) 28 (49) Work time Fulltime 7 (64) 8 (47) 15 (54) Parttime 4 (36) 9 (53) 13 (46) 34 Won. Is there a difference in adequacy of prenatal care for rural low income pregnant women who have extended travel and those who have little or no travel? Fifty-five women provided complete data to answer the research question. There were no statistically significant findings for the analyses of the three APNCU Indices (divided into four categories) by distance traveled: Initiation of prenatal care,.x’(3, nsSS) = 1.70, 92.636; Received services,.xz(3, n=55) = 2.05, p=.562; and Summary index, X’(3, n=55) = 3.48, 9:.324. However, over half (53%, n318) of the women with extended travel received less than adequate prenatal care according to the Summary index, compared to over a third (38%, n=8) of the women with little or no travel (Table 2). Examining adequacy of prenatal care by collapsing the four categories of the APNCU Indices into the two categories, adequate and less than adequate (Table 3), revealed similar findings to the first analyses (Table 2). There were no statistically significant findings for the analyses of the three APNCU Indices (divided into two categories) by distance traveled: Initiation of care, X’(1, n=55) = 1.16, p=.281; Received services, X” (1, n355) = .891, p:.345; and Summary Index, X2 (1, n=55) = 1.15, p=.284. Therefore, the findings in both analyses reveal that nearly half of the total study sample of rural low income pregnant women did not receive adequate prenatal care Table 2. ‘0l‘. ‘ O :O‘. o 35 APNCU Index Travel < 32 mi. Travel 2 32 mi. Total n (i) n (‘l n (3) Initiation of Prenatal Care Index Adequate Plus 9 (43) 13 (38) 22 (40) Adequate 10 (47) 14 (41) 24 (43) Intermediate 2 (10) 5 (15) 7 (13) Inadequate 0 ( 0) 2 ( 6) 2 ( 4) Received Services Index Adequate Plus 4 (19) 3 ( 9) 7 (13) Adequate 11 (52) 17 (50) 28 (51) Intermediate 6 (29) 13 (38) 19 (34) Inadequate 0 ( 0) 1 ( 3) 1 ( 2) Summary APNCU Index Adequate Plus 4 (19) 2 ( 6) 6 (11) Adequate 9 (43) 14 (41) 23 (42) Intermediate 6 (29) 10 (29) 16 (29) Inadequate 2 ( 9) 8 (24) 10 (18) Table 3. ‘0 '0 ‘ 0 :0‘9 - I- 0' APNCU Index Travel < 32 mi. Travel 2 32 mi. Total n (‘l n (3) n (A) Initiation of PNC Index Adequate 19 (91) 27 (79) 46 (84) Less than adequate 2 ( 9) 7 (21) 9 (15) Received Services Index Adequate 15 (71) 20 (59) 35 (64) Less than adequate 6 (29) 14 (41) 20 (36) Summary APNCU Index Adequate 13 (62) 16 (47) 29 (53) Less than adequate 8 (38) 18 (53) 26 (47) 36 but it appears that extended travel was not a significant factor in this sample. Discussion Sample In this descriptive study using secondary data, a total of 55 rural low income pregnant women's adequacy of prenatal care was analyzed on the variable of whether they had extended travel for prenatal care or not. Thirty-four women in this sample traveled 32 or greater miles (extended travel) one way for prenatal care and 21 women traveled less than 32 miles one way for prenatal care. Overall, the women who participated in the study were a fairly homogenous group. There were no statistically significant differences between the two groups of women by demographics. This is representative of the rural population in Michigan (Michigan Department of Public Health [MDPH], 1994). The majority of the sample consisted of married, White/Non-Hispanic women who had achieved at least a high school degree, which is consistent with the literature in its description of rural populations (Sherman, 1992). This study revealed no statistical significant difference in adequacy of prenatal care by distance traveled. The findings showed that over half of the study sample traveled greater than 32 miles one way for prenatal care. Some women without extended travel by study definition experienced access problems or geographic barriers associated with rural residency in receiving 37 adequate prenatal care. Defining extended travel as greater than 32 miles one way for prenatal care may not have provided a clear enough demarcation to distinguish between the two groups. The mileage of greater than 32 miles one way may have been too high, considering that this is rural travel. Other factors may also contribute to extended travel. Existing literature supports that access problems associated with geographical barriers could interfere with rural pregnant women receiving adequate prenatal care (McClanahan, 1992). These geographical barriers include, but may not be limited to, transportation problems, lack of public transportation, rural terrain, distance traveled, and inclement weather conditions (Fossett et al., 1991; Johnson et al., 1994; Sable et al., 1990). The percentage of women receiving less than adequate. prenatal care was high in both groups by the Summary index. This finding is consistent with the literature regarding rural low income pregnant women and adequacy of prenatal care (KIDS COUNT in Michigan, 1995; McClanahan, 1992). The fact that over half of the women with extended travel did not receive adequate prenatal care is a serious finding. Equally as serious is the fact that over one third of the women without extended travel also did not receive adequate prenatal care. Looking at initiation and continuity of prenatal care similar findings are revealed. While an association was not found between initiation of prenatal care and extended 38 travel, a higher percentage of women failed to initiate care until after the fourth month of pregnancy in the group with extended travel, compared to the group that did not have extended travel; in addition, the only women to have inadequate initiation of prenatal care and received services were in the extended travel group. While it should be noted that 80% of these women did initiate care by the fourth month of pregnancy, the fact that nearly one-fifth of the entire sample did not initiate care until after the fourth month of pregnancy should be of concern to all prenatal care providers. This finding is consistent with the current literature which states that rural low income women are more likely to initiate prenatal care later in the pregnancy, affecting their ability to receive adequate care when required to travel extended distances to access prenatal care or delivery services (Bushy, 1993; Horner et al., 1994; Leatherman et al., 1990; Nesbitt et al., 1990). This study may have failed to capture a significant association due to the fact that extended travel, defined as 32 miles (one way), may have been excessive mileage in determining the effects of extended travel on receiving adequate prenatal care. Any mileage over 10-15 miles (one way) may be a barrier to rural low income women in accessing adequate prenatal care. This would be supported by Horner et al. (1994) who found that nearly one-third of the population in their study did not travel beyond their home town for health care. Travel for care was reserved for 39 serious health concerns or initiation of care was delayed until resources could be evaluated. Previous studies which defined travel cited less mileage, such as McGuirk and Porell (1984) who looked at anything over 10 miles in determining if patients would travel to access health care services. With the geographical barriers associated with rural travel, significant differences may have been revealed if extended travel had been defined with less mileage or if the difference between the study groups had been more distinct. Not known also is how much the rural population is educated as to the importance of early prenatal care which may, in part, account for the fact that nearly one-fifth of the women in this study sample did not initiate prenatal care until after the fourth month of pregnancy. Women will travel extended distances when they perceive the services as valuable or worthy of travel (Horner et al., 1994; McGuirk & Porell, 1984). Again, it should be noted that over 80% of the women did initiate prenatal care early. Some low income rural women may wait until the pregnancy progresses and need for delivery services becomes a reality before initiating prenatal care, if the barriers are perceived as greater than the recognized value of the appointment. Another consideration is that the majority of these women were experiencing a second or more pregnancy and this may have influenced a woman's decision to initiate prenatal care. This is discussed in more detail later. 4o Initiation of care was not the only aspect of prenatal care which was troublesome in the findings of this study. The second index, which measured the number of actual prenatal visits of the expected number of visits also revealed that a higher percentage of women in both groups failed to continue prenatal care visits once care was initiated. Once again it must be stated that while a statistically significant association was not supported by the data, 41% of the women who had extended travel and 29% of the women who had little or no travel, received less than the recommended percentage of prenatal visits required for adequate prenatal care. Only 64% of the total sample completed the expected number of visits to receive adequate prenatal care throughout the pregnancy. For rural women to overcome barriers to access their initial visit may require less effort than overcoming barriers to receive multiple visits. Rural women may also perceive initiating care of a higher value than the “routine” prenatal care visits, making follow-up visits a lower priority than the initial visit. Not known is the amount of education that is done at each prenatal care visit or in this community regarding the importance of prenatal care which may affect the compliance or continuity of prenatal care visits. Another issue which may have affected the findings of this study was that most of the women in this study were experiencing their second pregnancy and may approach prenatal care differently than women who were pregnant for 41 the first time. It is possible that this factor could influence a woman's decision to initiate or complete recommended prenatal care visits both positively and negatively. It would make sense that if a woman has experienced a trouble free first pregnancy and felt confident with the information she received during her first pregnancy, she may choose to miss appointments or delay initiation if the barriers to receiving prenatal care exceeded what she perceived as a benefit of service. Due to the fact that most of these women were multiparous, additional responsibilities and potential barriers may complicate their ability to receive adequate prenatal care. These women must now contend with child care or extended child care if working outside of the home. If their child is ill they may not be able to attend their prenatal care visits. Over half of the women in the total sample worked outside of the home and with their low socioeconomic status it may be assumed that most women did not have jobs which would always compensate them for time off from work. Therefore, women need to prioritize their hours missed from work. If they miss days to care for sick children they may not also be able to miss work to receive prenatal care. If they are not compensated at all for hours missed at work, they may be unable to afford time off for prenatal care visits, regardless of their desire to attend. Many factors have been identified that may have contributed negatively to the lack of significant findings 42 in this study despite the unacceptably high number of women in both groups who did not receive adequate prenatal care. To improve the number of rural women who receive adequate prenatal care one must look at those who do receive adequate prenatal care, as well as those who do not. Perhaps one can better understand rural women who received adequate prenatal care by looking at the description of rural women presented by Bushy (1993). Rural women do not always have the same perspective of distance and time as non-rural residents. The women in this study who live in this rural county are perhaps used to extended travel to receive services. If they perceive the received service as valuable than they may be willing to tackle all the barriers to access this service, especially if they can combine tasks and benefit from trips to more populated areas. A trip to the “big city” may be viewed as an exciting and worthy event. Prenatal care may be an excuse perhaps to experience a trip to a more populated area, which is pleasurable to rural women (Bushy, 1993). For rural residents who are used to rural terrain and inclement weather these may not be barriers for them in accessing prenatal care services. Overall, in the findings of the three indices used to measure adequacy of care, both groups revealed an unacceptably high percentage of rural low income women who received less than adequate prenatal care. The size of the sample of this study, the absence of random sampling, and the definition of extended travel may account for the lack 43 of statistically significant findings between the two groups as well as parity and socioeconomic status. However, since there was an unacceptably high percentage of women with less than adequate prenatal care, primary providers must continue to look at ways to make prenatal care more accessible for larger numbers of rural low income pregnant women to receive adequate prenatal care. Western The results of this study provide some support for the adapted conceptual model of Starfield's (1992) model of the health care system. While the results supported travel under accessibility, it did not support “extended” travel. Women in both groups had similar adequacy of prenatal care patterns. The potential barrier which could affect rural low income pregnant women from accessing prenatal care was the need to travel extended distances to receive prenatal care, due to the closing of the obstetrical unit at the local hospital and the lack of prenatal providers in this rural county that offer prenatal care services through to delivery. To receive prenatal care in the third trimester and for delivery services (health care system), it was necessary for all rural women of this county to travel extended distances (approximately 30 miles) to nearby counties. Geographical barriers such as extended travel, inclement weather with rural travel, transportation problems, and extended time involved with extended travel (structure) can affect how rural low income pregnant women 44 utilize prenatal care services (utilization). These barriers can adversely affect the accessibility of services and could, therefore, affect a rural low income woman's ability to receive adequate prenatal care (Starfield, 1992). In this study almost half of the rural low income pregnant women did not receive adequate prenatal care. Although this study could not report a statistically significant association between extended travel for prenatal care and less than adequate prenatal care, the findings did reveal a trend in that direction, supporting this model, which demands further investigation. The findings of the study provided evidence for the model which shows that utilization of services is affected by the structure (the accessibility of services) regardless of distance, and that low income rural women with any travel may have difficulty utilizing the services of prenatal care to meet the outcome of adequate prenatal care. This study looked at the effects of extended travel as a geographical barrier to accessing prenatal care. Added to the model was the potential impact on the definition of the variable, Sextended travel,” by the social/physical environment of the rural low income pregnant women. Bushy (1993) reports a need to look at the physical and psychological attributes of rural women to better understand and plan for the health care of rural populations. For the purpose of this study, therefore, the rural low income status of this study sample was located under process, while 45 also acknowledging the potential effect of the social/ physical environment on the perception of extended travel for this study and rural populations of future studies. He . '.. . ;. .. -. - . ' - ( ~'.. '. - u... . ; Adequate prenatal care, which involves early and consistent prenatal care, remains the standard of care in this country as set forth by the American College of Obstetricians and Gynecologists, to increase positive birth outcomes (Freeman & Poland, 1992). Studies have identified groups of people at risk for receiving less than adequate prenatal care such as low income and rural women (Goldberg et al., 1992; Horner et al., 1994; Johnson et al., 1994; Schaffer & Lia-Hoagberg, 1994). Perhaps, however, the ACOG standards for routine prenatal visits for low risk women needs to be further examined regarding the necessity and realistic need for first-time and not first-time pregnant women. This study revealed that the percentage of low income women who received adequate prenatal care in this small rural county in Michigan fell far short of the Healthy Michigan 2000 objective to have 90% of all pregnant women receiving adequate prenatal care (KIDS COUNT in Michigan, 1994). Recognizing that rural low income women are not receiving adequate care, regardless of whether they travel extended distances or not, is an opportunity for APNs to function in the role of researcher to decrease the barriers and increase access to prenatal care to rural residents in 46 their counties. Identification of travel issues in accessing prenatal care needs to be addressed, such as out of county prenatal care facilities, transportation problems, need for longer child care, and increased amount of work hours missed for prenatal visits. It was found that women who were classified as having less than adequate prenatal care were in fact, primarily in the intermediate category. Most women were initiating prenatal care by the fourth month and receiving some prenatal care, they were just falling short or experiencing difficulty in receiving continuous, comprehensive prenatal care per ACOG standards. As a researcher, the APN is able to utilize this information in helping to decrease the barriers which may be interfering with the ability of these rural low income women in receiving continuous prenatal care. One approach may be to conduct an assessment of the effect of travel through a study which includes an exit interview of women's adequacy of prenatal care and reasons for late entry and/or missed appointments. Included would be an evaluation of the findings and then planning, implementing and evaluating office/clinic time spent at the office/clinic visit and perceived value of time spent. This model might identify travel barriers such as daytime hours only, child care needs, and missed work. The information received in the interviews would direct the planning of the way future prenatal care is offered. The APN, as a client advocate and change agent, can work collaboratively with 47 county planners to affect change within the prenatal care delivery system. Change which may include the provision of prenatal care services within the county via satellite. offices, offering evening and weekend hours, and on site child care facilities, eliminating the need for women to travel extended distances for all of their prenatal care. Another major role for the APN is that of educator. The large percentage of women who initiated care after the fourth month of pregnancy suggests the need for increased education of rural women regarding the importance of early and continuous prenatal care, as well as how to access prenatal care services. Studies indicate that if women recognize the value of health care services, they will travel further to receive it (Horner et al., 1994; McGuirk & Porell, 1984). Women need to have made available to them options for obtaining prenatal care if travel is a barrier. Establishing transportation for prenatal care such as through church and community support groups is one means to assist women in accessing prenatal care. The provision of volunteer child care services may be another means of decreasing the barriers and increasing access. Everyone in the community needs to be educated regarding the importance of prenatal care and ways to assist women in initiating and continuing prenatal care. The APN needs to assess if pregnant women believe their needs are being met, and if not, why not. The APN can assess the community regarding 48 ways the community as a whole can mobilize efforts to assist pregnant women in attending prenatal care services. Advanced practice nurses as primary care providers are able to provide primary care to women before, during, and after pregnancy. As a primary care provider, the APN can function in the roles of collaborator and educator. As an educator, the APN can provide preconception counseling; if a woman becomes pregnant, the APN can assist her in accessing a prenatal care provider. The APN in the role of collaborator, remains in contact with the women with phone contacts and through follow up communication with the referral prenatal provider. The APN can also explain and clarify procedures and tests and encourage regular attendance at prenatal care visits. The APN needs to be visible in the community in areas where rural women frequent, such as day care centers, community centers, and churches. The APN can provide information about preconception and prenatal care through local fairs, community gatherings, and by utilizing local publications. By speaking at local establishments such as health departments, schools, and churches, the APN can educate women and the community as to the importance of early and continuous prenatal care, as well as identify ways to make early and continuous prenatal care a viable option for all women. 49 W While this study failed to show an association between extended travel and adequacy of prenatal care, it did reveal that almost half of the rural low income women in this study did not receive adequate prenatal care. Previous studies have failed to isolate and or define the barrier of travel even when they cited transportation and travel as barriers to prenatal care. The literature review revealed that very little research has been conducted which examines the extent to which.hextended travel” is a barrier to receiving adequate prenatal care for rural low income pregnant women. The failure of this study to find an association may, in part, be do to the small sample size and/or the way which extended travel was defined in this study. Replication of the original study with a larger sample size is warranted. A replication of this study with a larger sample, which redefines extended travel so that the mileage difference between the two groups, those with extended travel and those without extended travel, is more distinctly divided is warranted. Redefining the variable “extended travel" may be as follows: The use of standard deviations above and below the mean; or by lowering the mileage requirement for “extended travel,” which may produce more distinct differences between the study groups and perhaps reveal significant differences in a follow up study. An assessment of the time involved in receiving prenatal care as a barrier to rural low income pregnant women receiving adequate 50 prenatal care may be warranted. This would be helpful in determining if it is the geographical barrier or if it is the time involved in receiving care, including potential loss hours of work, that prevents women from initiating and continuing prenatal care. This would also help determine if the assessment that rural women expect to travel extended distances for care and, therefore, do not see travel mileage as a barrier to receiving adequate prenatal care is accurate (Bushy, 1993). Additional research includes studies which determine if a patient is satisfied with the care received in proportion to the travel expended for each visit and what motivates a woman to travel extended distances and invest hours of time to receive each prenatal care visit. This study identified the need to further delve into travel and adequacy of prenatal care by rural low income women that still are not receiving adequate prenatal care. This may provide insights into areas for improvement within the prenatal care delivery system. Summary This study compared two groups of rural low income pregnant women, those that had extended travel for prenatal care and those who had little or no travel for prenatal care, as to whether they received adequate prenatal care as measured by the Kotelchuck Adequacy of Prenatal Care Index (1994a). The findings of this small descriptive study tend to support that rural populations, particularly those with low socioeconomic status, receive less than adequate 51 prenatal care through delayed initiation of prenatal care and lack of continuity of prenatal care visits. By further investigating the effect of travel for rural low income pregnant women the APN with other health care professionals and community leaders can develop a prenatal care delivery system which decreases the geographical barrier of extended travel. By decreasing extended travel to prenatal care, better access to prenatal care is advocated offering rural low income pregnant women the opportunity to receive adequate prenatal care. LIST OF REFERENCES LIST OF REFERENCES Alexander, 6., & Cornely, D. (1987). Prenatal care utilization: Its measurement and relationship to pregnancy outcome. Amer1can_Journal_of_Presentatixe_nedicine1_1(5). 243-252. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists. (1992). Guidelines_for_nerinatal_care 3rd ed. Elk Grove Village. 11: AAP. Bronstein, J., & Morrisey, M. (1990). Determinants of rural travel distance for obstetrics care. Medical_§azg+ 23(9), 853-865. Bushy, A. (1993). Rural women lifestyles and health status. Nurs1ng_Cl1nics_of_north_America1_28t1). 187-197- Dutton, D. (1986). Financial, organizational and professional factors affecting health care utilization. Social_Science_Medicine1_23(7), 721- 735. Fossett, J., Perloff, J., Kletke, P., & Peterson, J. (1991). Medicaid patients' access to office-based obstetrics. Journa1_of_Hea1th_Care_for_the_Eoor_and Underseryed1_1(4). 405- 420. Freeman, R. K., & Poland, R. L. (1992). Guidelines for_perinatal_care (3rd ed. ). American College of Obstetricians and Gynecologists and American Academy of Pediatrics. Goldberg, R., Patterson, E., & Freese, M. (1992). Maternal demographic, situational and psychosocial factors and their relationship to enrollment in prenatal care: A review of the literature. Women_§_flealth+12(2/3), 133-151. Hangsleben, K., Jones, M., Lia-Hoagberg, B., Skovholt, C., & Wingeier, R. (1995). Medicaid and non-Medicaid prenatal care by nurse-midwives. Amerigan_§gllege_of_flnrfie: Midniyesl_an(4), 320- 327. 52 53 Horner, S., Ambrogne, J., Coleman, M., Hanson, C., Hodnicki, D., Lopez, 8., & Talmadge, C. (1994). Traveling for care: Factors influencing health care access for rural dwellers. 2nbl1c_Health_Nursinsl_11(3). 145-149- Johnson, J., Primas, P., & Coe, M. K. (1994). Factors that prevent women of low socioeconomic status from seeking prenatal care. ’ Practitieneral_§(3), 105-111. Joyce, K., Diffenbacher, G., Greene, J., & Sorokin, Y. (1984). Internal and external barriers to obtaining prenatal care. S9c1a1_Work_in_flealth_care1_2(2). 89-96- Katz, 8., Armstrong, R., & LoGerfo, J. (1994). The adequacy of prenatal care and incidence of low birthweight among the poor in washington state and british columbia. ' ° (6), 986-991. KIDS COUNT in Michigan. (1994). Michigan_k1ds_connt beinsl KIDS COUNT in Michigan. (1995). Michigan_kids_cnnnt beings - Kotelchuck, M., (1994a). Presented at the University of North Carolina at Chapel Hill, September, 1994. Kotelchuck. M-. (1994b). Adequac¥_9f_nrenatal_care Presented at the University of North Carolina at Chapel Hill, September, 1994. Kotelchuck, M., (1994c). An evaluation of the kessner adequacy of prenatal care index and a proposed adequacy of prenatal care utilization index. ° Health1_84(9), 1414-1419. Leatherman, J., Blackburn, D., & Davidhizar, R. (1990). How postpartum women explain their lack of obtaining adequate Prenatal care. Journal_gf_Adyanced_Nnrs1ng1_15. 256-267. Lieber, M. (1994). The experiences of a sample of rural women during pregnancy. 1onrnal_9f_Commun1t¥_Health Nursin91_11(2). 79-87- McClanahan, P. (1992). Improving access to and use of prenatal care. ' ' Neonatal_Nursins1_21(4). 280-284- 54 McDonald, T: P-r 5 Coburn, .A. F. (1988). Predictors of prenatal care utilization. ° - - - 21(2). 167- -172. McDuffie, R., Beck, A., Bischoff, M., Cross, J., 8 Orleans, M. (1996L Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. JAMA1 215(11), 847- -851. McGuirk, M., & Porell, F. (1984). Spatial patterns of hospital utilization: The impact of distance and time. Innuir¥1_211 84- -95 Meikle, S., Orleans, M., Leff, M., Shain, R., & Gibbs, R. (1995). Women's reasons for not seeking prenatal care: Racial and ethnic factors. Birth1_22(2). 81-86. Michigan Department of Public Health. (1992). Infant Death_Renort1 Michigan Department of Public Health. (1994). Infant Death_Renortl Nesbitt, T., Connell, F. Hart, G., & Rosenblatt, R. (1990L Access to obstetric care in rural areas: effect on birth outcomes. American_lournal_of_2ublic_Health1_80(7). 814-818. Omar, M. A., & Schiffman, R. F. (1994). Patient f1nal_repgzt1 Unpublished manuscript. Omar, M. A., & Schiffman, R. F. (1995). Pregnant women's perceptions of prenatal care. Materna1_:£hild Nursing_lonrnall_23(4). 132 142- Omar. M. A., Schiffman, R. F., & Bauer, P. (1995). 0 ‘0 0 0 9 ‘09 . ._ ‘ . . o. .0. cl! Il- ‘ 0- '0' Final report presented to All University Research Initiation Grant Support. November 15,1995. Unpublished manuscript. Raine, T., Powell, S., & Krohn, M. A. (1994). The risk of repeating low birth weight and the role of prenatal care. (4), 485- 489. Sable, M. R., Stockbauer, J. W. Schramm, W. F., & Land, G. H. (1990). Differentiating the barriers to adequate prenatal care in Missouri, 1987- -88. Enb119_Health Reportsl_105(6). 549 555 55 Schaffer, M. A., & Lia-Hoagberg, B. (1994). Prenatal care among low-income women. Familigs jn sggjggy; Ihg Journa1_of_Contemnorx_numan_5eryicesi 152-159. Sherman. A- (1992). Eallins_bY_the_na¥sidei__Ch1ldren in_znral_Ameriga1 Washington, DC: Children's Defense Fund. Starfield, B. (1992). Primar¥_carei__concentl exalnatign_and_ngligy. New York, New York: Oxford University. United States Department of Health and Human Services. (1990). - ' ' (DHHS Publication No. (PHS) 90-62772). York, R., Grant, C., Gibeau, A., Beecham, J., & Kessler, J. (1996). A review of problems of universal access to prenatal care. Nurs1ng_911n1cs_of_North_America1 31(2), 279-293. APPENDIX A PROCEDURES FOR DATA COLLECTION 56 APPENDIX A PROCEDURES FOR DATA COLLECTION Original Study by Omar, Schiffman, and Bauer Data collectors were selected and prepared by the principal investigator and co-principal investigators, Omar et al., (1995). Potential participants were identified by the data collector in conjunction with the staff at local health departments, physician offices, and childbirth education classes, and eligibility for participation was verified utilizing inclusion criteria (able to read, write, and understand English, reside in the rural county in lower Northern Michigan and be of low income status as determined by the eligibility criteria for the Women, Infant, & Children (WIC) program, i.e., being at or below 185% poverty level). Solicitation for participation was done by the data collector explaining the study to potential women in the waiting rooms of local health departments, physician offices, and at childbirth education classes. Women were in their third trimester of pregnancy, but all had completed at least three prenatal visits. Confidentiality was assured to all prospective participants. Informed consent to voluntarily participate in the study was obtained with a signed consent form prior to survey distribution. Willing and eligible participants were provided a cover letter explaining the study, the instrument, and an envelope in which to place the completed questionnaire. The women read 57 the cover letter and instructions, and completed the instrument. The data collector was available to answer questions and provide instructions. Participants placed the completed questionnaire in the envelope provided, and received a cash incentive of $10.00. The completed surveys were returned to the primary investigators. Data collection commenced in June 1994 and was completed in July 1995. APPENDIX B MATERNAL SELF-REPORT HEALTH AND PRENATAL CARE UTILIZATION SURVEY 58 ID Maternal Self-Report Health and Prenatal Care Utilization Survey Thank you for participating in our study and helping us find out how it's been for you getting health and prenatal care for yourself. Please answer the questions specifically about you. 1. 2. When is your baby due? / / month day year How many other children do you have at home? How old are they (please list all ages). What is your county of residence? What is your city or town of residence? How long have you lived in this county? Where do you go for your prenatal care? Please list the name or names and location of the doctors, or clinic where you get your prenatal care and the distance traveled one way. Name of Doctor/Clinic City/Distance Traveled (one way) APPENDIX C OTHER'S HOSPITAL CHART RECORD REVIEW 59 Michigan State University College of Nursing Benzie County Project Mother's Hospital Chart Record Review E . l] H E . I' CAREWEEK Weeks of gestation when woman first obtained prenatal care PREVISIT Total number of prenatal visits for routine assessments (read notes carefully) MISSEDAP Total number of missed appointments those not canceled, i.e., “no show” PREWT Woman's weight at entry into prenatal care LASTWT Woman's weight at the time of delivery in pounds DDELMN Month of delivery DDELDY Date of delivery DDELYR Year of delivery Infant's Hospital Birth Record Review SEXBABY Sex of Baby 1=female 2=male MULTIBIR Multiple birth 1=twins 2=triplets BIRTHWT Birthweight in grams GSTATION Length of gestation in weeks BIRANOM Major birth anomaly RNICU Infant admitted to special care nursery over 24 hours APPENDIX D PATIENT SATISFACTION WITH PRENATAL CARE SURVEY 92. 93. 94. 95. 96. 97. 98. 60 Patient Satisfaction with Prenatal Care Survey‘ Age (in years) Race (check only one) Asian Black Hispanic Native American White (Non-Hispanic) Other (Please Specify) Mark the highest level of education you have ggmnlgtgd (check only one): Less than / high school Some high school High School Graduate/GED Some College/Technical School College Graduate Post Graduate l l Mark the response which currently describes your marital status (check only one): Single Divorced Married Separated Widowed Other (Please Specify) Are you working outside the home? No Yes If yes, Fulltime Parttime What kind of insurance do you have? (Check all that 3PP1Y) Medicaid Private Insurance Michcare None (Self Pay) Counting this pregnancy, how many times have you been pregnant? . APPENDIX E UNIVERSITY COMMITTEE ON RESEARCH INVOLVING HUMAN SUBJECTS OFFICE OF RESEARCH AND GRADUATE STUDIES University Committee Research Involving Human Suhiect: (UCRIHS) Michigan State University 246 Administration Budding East Lansing, Michigan 4&94NM6 517/355-2180 FAX SI7/432'IIII Inc Micmoan Stare Universny 10M :5 Insurimoml Diversuy harm: on Action MSU IS an amnrurive-xhon. equal ~0000flunrry mslllullOfl 61 MICHIGAN STATE UNIVERSITY January 15, 1998 TO: Mildred A. Omar A-230 Life Sc1ences RE: IRsnz 97-882 TITLE: ADEQUACY OF pERNATAL CARE FOR Low INCOME WOMEN WITH EXTENDED TRAVEL IN RURAL SETTINGS REVISION REQUESTED: N/A CATEGORY: 1-E APPROVAL DATE: 01/05/98. The University Committee on Research Involving Human Subjects'IUCRIHSl rev1ew of this project is complete.. I am pleased to adv18e that the rights and welfare of the human subjects appear to be adequately rotected and methods to obtain informed consent are appropriate. ngrefore, the UCRIHS approved this project and any rev1sions listed a ve. RENEWAL: UCRIHS approval is valid for one calendar year, beginning with the approval date shown above. Investigators plann1ng to continue a project be ond one year must use the green renewal form (enclosed w1th t e orig1nal agproval letter-6r when a. prOJect 1s renewed) to seek u date cert1f1cat1on. There IS a maximum of four such expedite renewals pos81ble. Investigators wishin to continue a project beyond that t1me need to sumet 1t aga1n or complete rev1ew. REVISIONS: UCRIHS must review any changes in procedures involving human subjects, rior to initiation of t e change. If th1s Is done at the time o renewal, please use the green renewal_form. To reV1se an approved protocol at an other t1me during the year, send your written request to the CRIHS Chair, request1ng rev1sed approval and referencing the project's IRB # and t1tle.i Include In {our request a description of the change and any rev1sed Ins ruments, consent forms or advertisements that are appl1cable. PROBLEMS / CHANGES: Should either of the followin arise during the course of the work, Investigators must noti UCRIHS promptly: $1) roblems (unexpected s1de effects, comp aints, etc.) involv1ng uman subjects or (2) changes in the research environment or new 1nformat1on Indicating greater risk to the human sub ects than ex1sted when the protocol was previously reviewed an approved. If we can be of any future help, please do not hesitate to contact us at (517)355-2180 or FAX (517)4 2-1171. 1d E. Wright, Ph.D CRIHS Chair ‘ DEW2bed cc: Terri Glenn Sincerely, MICHIGAN STATE UNIV. LIBRARIES IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 31293017074323