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This is to certify that the

dissertation entitled

DISPARITIES IN GAINING ACCESS TO PRENATAL CARE: LOW-INCOME
MEXICAN AMERICAN WOMEN'S SOCIAL RESOURCE MANAGEMENT

presented by

Molly A. Lauck

has been accepted towards fulfillment
of the requirements for

Ph.D. Anthropology

degree in

 

 

j... 1/ 11m:

J/ajor professor

Date 'Z/S/OO

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' Michigan State

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PLACE iN REI'URN BOX to remove this checkout from your record.
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DAE DUE DATE DUE DATE DUE
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izb‘izzmzifi i ’§ iii}. ii 5

A

 

, JAN 2 4 2005

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DISPARITIES IN GAINING ACCESS TO PRENATAL CARE: LOW-INCOME
MEXICAN AMERICAN WOMEN'S SOCIAL RESOURCE MANAGEMENT

By

Molly A. Lauck

A DISSERTATION

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

DOCTOR OF PHILOSOPHY
Department of Anthropology

2000

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ABSTRACT

DISPARITIES IN GAINING ACCESS TO PRENATAL CARE: LOW-INCOME
MEXICAN AMERICAN WOMEN'S SOCIAL RESOURCE MANAGEMENT

By

Molly A. Lauck

In this study, I take up prenatal care as a domain in which pregnancy and birth
provide opportunities to examine ordinary health issues specific to women in the context
of health care institutions and everyday decision making. Specifically, I focus on how
low-income Mexican American women gain access to prenatal care and how this process
is linked to their management of social resources, health care clinic personnel's
perspectives on women's social resource management, and the role "cultural competency"
plays in clinic personnel's views of this process.

The participants' views and experiences analyzed in this dissertation were drawn
fi‘om ethnographic research conducted in Lansing, Michigan. Data were collected in
three obstetric/gynecology clinics that serve low-income women — a Latino community
health center clinic, a public health clinic, and a hospital based clinic. Data for this
research were collected in two phases. The first phase involved participant observation
and open-ended interviews with low-income Mexican American women who lived in the
Greater Lansing area, addressing the strategies they developed to gain access to

biomedical health care during pregnancy and birth. Phase two focused on investigating

   
 
    
  

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clinic personnel's perspectives of low-income Mexican American women's access to
prenatal care using these same methods.

Drawing upon concepts from critical medical anthropology and developing a
concept of women's social resource management, I suggest that women make decisions
and thus develop strategies to gain access to prenatal care that are shaped by both
political and economic issues. For example, women in this study often relied upon a
friend to drive them to their prenatal appointments. While clinic personnel identified
socioeconomic issues, such as transportation problems, that women faced, they often
conceptualized such problems as isolated issues or barriers rather than viewing them as a
series of interconnected events that women addressed through the social and economic
resources available to them. I argue that this distinction is significant for it addresses a
fundamental premise of clinic personnel's conceptualization of the term "barrier." Clinic
personnel perceived barriers in terms of a patient's contact with a physician or prenatal
clinic. As a result, women in this study perceived "access" as an event that preceded and
eventually led to a clinical encounter in contrast to clinic personnel who conceptualized
"access" as an action bounded by the clinic.

Recognizing the dichotomy between women and clinic personnel's
conceptualizations of what is involved in achieving access to prenatal care sheds new
light on the process of gaining access to care. This study concludes that low-income
Mexican American women's access to prenatal care is more significantly influenced by
women's management of the social resources available to them in contrast to clinic
personnel's explanations of access that are premised upon a conceptual fiamework of

cultural competency.

 

 

 

COPETig'fi:
M011) An
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Copyright by
Molly Ann Lauck
2000

ACKNOWLEDGEMENTS

The completion of this dissertation is a triumph to which I must credit a number
of people. My parents, Margaret Schylling and Richard Lauck, gave me their undying
support — urging me forward despite the inevitable obstacles inherent of graduate
education. In particular this dissertation in a tribute to my father. The endless
discussions we have had over the years about anthropological theory and the role of
language have shaped not only this dissertation, but also my development as a scholar as
a whole.

I owe my committee, Ann V. Millard, Maria Montoya, Judy Pugh, Barbara
Rylko-Bauer, and Scott Whiteford, a great deal of thanks as they invested a significant
amount of time and energy in both the research and writing processes. In particular, my
committee chair, Ann V. Millard, offered me support and compassion that I believe far
exceeded the normal bounds of the advisor/advisee relationship.

The process of researching and writing this dissertation was an arduous endeavor
that often left me feeling overwhelmed — "Would I ever finish?" Consequently, my
father often jokingly referred to me as "the jaded graduate student." Thankfully I had
three other "jaded graduate students" whomI could rely upon to help me see the humor
of this educational process: Carrie Alexander, Mariaelena Jefferds and Julie Reyes. As a
result of many serious and not-so-serious discussions about anthropological issues with

these women, I acquired three very dear friends.

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drafted the

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Finally, I give my love and thanks to my husband, Andrew Harris, who supported
me emotionally, intellectually, and financially while acting as my technical advisor
throughout the writing process. Most importantly however, both he and my son

Benjamin showed me the importance of striving to achieve one's goals. Thank you.

vi

 

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CHAPTER 3:

TABLE OF CONTENTS

LIST OF FIGURES ................................................................................ x
CHAPTER ONE: INTRODUCTION ............................................................................. 1
WOMEN'S RESOURCE MANAGEMENT ..................................................................... 1
CLINIC PERSONNEL'S MISCONCEPTIONS ................................................................ 6
THEORETICAL CONCEPTS AND CRIITCAL APPROACHES TO HEALTH CARE .............. 8

The Politics and Economics of Social Resource Management ......................... 8
Conceptualizations of Health Care "A ccess " and "Barriers" ........................ 15

Barriers to Entry ..................................................................................... 17

Ethnicity and Health Research ................................................................ 20

Cultural Competency .............................................................................. 22

Other Conceptual and Theoretical Issues ..................................................... 26

Gender Centered Approach .................................................................... 26

Tacit Knowledge: Negotiating Access to Health Care Services ............... 27

ENDNOTES .......................................................................................................... 29
CHAPTER 2: METHODS ............................................................................................ 30
SAMPLING STRATEGIES ....................................................................................... 31
Criteria for Selecting Women ....................................................................... 32

Latino Community Center Clinic ............................................................ 32

Public Health Clinic ............................................................................... 33

Hospital Clinic ....................................................................................... 34

Criteria for Selecting Clinic Personnel ......................................................... 35
OPEN-ENDED INTERVIEWS .................................................................................. 36

Phase I ......................................................................................................... 36

Phase II ....................................................................................................... 37
PARTICIPANT OBSERVATION ............................................................................... 39

DATA ANALYSIS ................................................................................................. 42
Qualitative Data .......................................................................................... 42
Quantitative Data ........................................................................................ 43
ENDNOTES .......................................................................................................... 44
CHAPTER 3: THE PARTICIPANTS AND THEIR SETTINGS ............................... 45
THE COMMUNITY ............................................................................................... 46

THE CLINICS ....................................................................................................... 50

The Latino Community Center Clinic ........................................................... 50

The Hospital Clinic ...................................................................................... 54

The Public Health Clinic .............................................................................. 58

THE PARTICIPANTS ............................................................................................. 63

The Clients ................................................................................................... 63

The Clinic Personnel .................................................................................... 64

vii

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ENTERING THE FIELD .......................................................................................... 65
ENDNOTES .......................................................................................................... 70

CHAPTER 4: WOMEN'S SOCIAL RESOURCE MANAGEMENT AND

 

STRATEGIES -- - ........... . -- - - - “-71
WOMEN'S SOCIAL RESOURCES ............................................................................ 72
Why Women Think They Need Prenatal Care ............................................... 72
How Women Find Out about and Choose 0 Clinic ....................................... 78
Finding Out about and Enrolling in Medicaid .............................................. 82
WOMEN'S SOCIAL RESOURCE MANAGEMENT AND STRATEGIES ............................ 87
Interview — Maria ....................................................................................... 88
Interview — Rosie ........................................................................................ 89
Interview — Theresa .................................................................................... 92
DISCUSSION ........................................................................................................ 94
ENDNOTES .......................................................................................................... 99

CHAPTER 5: CLINIC PERSONNEL'S VIEWS OF WOMEN'S ACCESS TO

PRENATAL CARE ................................................................................................... 100

CLINIC PERSONNEL'S PERSPECTIVES .................................................................. 101

Why Women Obtain Prenatal Care ............................................................ 101

How Women Find Out about and Choose a Clinic ..................................... 104

Finding Out about and Enrolling in Medicaid ............................................ 106

CLINIC PERSONNEL'S PERSPECTIVES .................................................................. l 10

Interview — Cory ....................................................................................... l l 1

Interview — Diane ................................................................................ 1 13

DISCUSSION ...................................................................................................... l 16

CHAPTER 6: CULTURAL COMPETENCY ........................................................... 120

OBTAINING PRENATAL CARE: BARRIERS AND ETHNICITY .................................. 122

Socioeconomic Barriers and the Ethnic Context ......................................... 123

CULTURAL COMPETENCY ................................................................................. 129

CHAPTER 7: CONCLUSIONS ................................................................................. 134
SOCIAL RESOURCE MANAGEMENT: WOMEN'S STRATEGIES & CLINIC PERSONNEL'S

MISCONCEPIIONS .......................... '. .................................................................. 134

DIVERGING PERSPECIIVES OF ACCESS .............................................................. 136

APPENDICES ........................................................................................................... 142

APPENDIX A: INTERVIEW GUIDE — WOMEN SEEKING CARE ................... 143

APPENDIX B: INTERVIEW GUIDE — CLINIC PERSONNEL ........................... 145

APPENDIX C: AGGREGATE DATA FROM INTERVIEWS WITH WOMEN

SEEKING PRENATAL CARE ................................................................................ 147

Part I ......................................................................................................... 147

Part II ........................................................................................................ 151

viii

APPENDI l D
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APPENDIX D: AGGREGATE DATA FROM INTERVIEWS WITH CLINIC

 

PERSONNEL —- - - - - ------ - - -- -- -- - - 153
Part I ......................................................................................................... 153
Part II ........................................................................................................ 155
REFERENCES CITED ............................................................................................. 160

 

 

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Latino Community Center Clinic ............................................................. 52
Hospital Clinic ...... g ..................................................................................... 5 6
Public Health Clinic ................................................................................... 59
Why Women Value Prenatal Care ............................................................ 73
How Women Find Out about Prenatal Care ............................................ 76
Basis of Women's Clinic Choice ................................................................ 79
Women's Work Activities in Pregnancy ................................................... 83
Clinic Personnel's Views on Why Women Obtain Prenatal Care ......... 102
Clinic Personnel's Explanations of How Women Find Out about

Prenatal Care ....................................................................................... 105
Quality of Coverage: Medicaid Vs. Private Health Insurance ............... 107
Why Clients Do Not Have Health Insurance: Clinic Personnel's

Explanations ........................................................................................ 109
Socioeconomic Barriers to Gaining Access to Prenatal Care ................ 124
Barriers Specific to Low-Income Mexican American Women .............. 126
Why Women Do Not Work During Pregnancy ...................................... 128

 

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Chapter One: Introduction

Women's Resource Management

In this analysis, I take up prenatal care as a domain in which pregnancy and birth
provide opportunities to examine ordinary health issues specific to women in the context
of health care institutions and everyday decision making. Specifically, I focus on how
low-income Mexican American women gain access to prenatal care and how this process
is linked to their management of social resources, health care clinic personnel's
perspectives on women's social resource management, and the role "cultural competency"
plays in clinic personnel's views of this process.

Research on the process of gaining access to health care has traditionally focused
on how health services are used (Loue, 1999; Strickland and Strickland, 1996), whether
or not people have been able to obtain needed medical services (Chrisman, 1977; Igun,
1979; Suchman, 1965) and barriers that prevent the use of services (Estrada etal., 1990;
Kasper, 2000; Trevino etal., 1991). For the most part, these models have focused on
aspects of the individual that determine use, deflecting attention away from the process
involved in gaining access to health care services. In contrast, I argue that an individual's
use of the social resources available to her are a more significant indicator of how she
will obtain needed medical care and any barrier that might prevent her from using a
specific health service. I shifi the focus to women's management of social resources to
examine women entering the health care system as an active process of gaining access to

prenatal care grounded in everyday experience. My study thus explores the process of

 

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gaining access to health care — that is, the decisions women make and the social
resources they manage prior to entering a health care facility.

In this analysis, I focus on how the resources that are available to women shape
the decisions that they make in the process of gaining access to prenatal care. In this
dynamic process women draw upon social, economic, and even medical resources for aid
in their decision making. For example, this study finds that a greater Lansing public
health department gives a woman a list of prenatal clinics to choose from when she
enrolls in Medicaid. Choosing a clinic from the list is not straightforward however. A
woman must evaluate variables such as the location of the clinic relative to her home,
whether the clinic is on a bus route, and whether she will be able to get time off from
work to attend her appointment. While choosing a clinic from a list provided by the
public health department might seem like the first step in the process of gaining access to
prenatal care for many low-income women, it is presupposed by the action of finding out
about and applying for Medicaid. The decision making process of gaining access to
prenatal care draws upon women's social resources outside of the medical and Medicaid
systems. For example, women in this study often found out about Medicaid through
social networks composed of family members, friends and co-workers from whom they
learned what services Medicaid covered and where they could enroll in it. Women
further relied upon these social networks to facilitate the enrollment process — asking a
friend from work to trade shifts with them while they spent the afiemoon at the public

health department, borrowing a parent's car to drive to the appointment, and depending

upon a sister to help fill out the application for Medicaid.

 

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In his ethnography, "The Quest for Therapy: Medical Pluralism in Lower Zaire,"
John Janzen presents an "on the ground ethnographic account of how medical clients of
one region of Lower Zaire diagnose illness, select therapies, and evaluate treatments," a
process he calls "therapy management" (19782xviii). Through a series of case studies he
portrays the various medical options available to the BaKongo people of Lower Zaire as
well as the intricate measures of the decision making process taken by what he
characterizes as the therapy managing group:

A therapy managing group comes into being
whenever an individual or set of individuals
becomes ill or is confronted with
overwhelming problems. Various maternal
and paternal kinsmen, and occasionally their
friends and associates, rally for the purpose
of sifting information, lending moral
support, making decisions, and arranging
details of therapeutic consultation. [Janzen,
197824]

Similarly to Janzen's concept of a therapy managing group, the social networks
women in this study relied upon fundamentally shaped their knowledge about prenatal
care and clinics, lent moral and financial support, and were integral to their decision
making process as well as facilitating a woman's access to a clinic by offering childcare
and transportation. In contrast to Janzen's concept, where women who were ill passively
accepted the decisions made on their behalf by their therapy managing group, the women
in this study actively made conscious decisions about their care drawing from the
resources available to them through their social networks. In general, women relied upon

three types of social networks: family-based networks, friend-based networks, and work-

related networks. Family-based networks included women's immediate and extended

 

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kin, their partners and any relatives of their partners as well. Friend-based networks were
comprised of people women met as neighbors and childhood friends, and through school,
church, and other social gatherings. Finally, women's work-related networks included
colleagues as well as contacts made through their colleagues. While each of these
networks were largely separate, women in this study configured their use of the networks
diflemntly. For example, one woman might rely primarily upon her family-based
network for information about prenatal clinics and to meet her transportation needs
whereas another woman might rely upon her fi'iend-based network for information about
prenatal clinics and upon her work-related network for transportation. Similarly, some
women might have only had one network to draw upon whereas another could rely upon
all three of the networks.

As discussed above, finding out about, choosing, and using a clinic for prenatal
care is far more involved than simply choosing a clinic from a list. As such, the decisions
that women make in gaining access to care are not isolated or independent events but
rather a series of actions that are linked together with the aim of achieving a specific goal.
The interdependency of these actions is the essence of the strategies that women develop
to gain access to prenatal care. For example, afier learning about Medicaid from her
parents, enrolling in Medicaid with her sister's help, and receiving a list of prenatal
clinics from the public health department, a woman might choose a prenatal clinic based
upon whether she will have to take a bus or have the use of her husband's car to attend
her prenatal appointments. Consequently, women draw upon the resources available to

them to create strategies to gain access to prenatal care.

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As women go through pregnancy and birth, they achieve access to prenatal care
through a series of decisions and routines that I analyze as social resource management.
For the purpose of this study, I define social resource management as a process in which
women draw upon their social networks -— in the form of kin-based, fiiend-based and
work-related networks — to address issues of childcare, transportation, working both in
and out side of the home, and unemployment in facilitating access to prenatal care.
Similar to a social capital framework of analysis, I posit that relying upon social networks
is a typical strategy of low-income people, as they often have no other resources available
to them. Whereas a social capital fiamework portrays networks as given entities
measured in terms of the numbers of ties or connections between people and cost-benefit
analysis, I use the concept of social resource management to actively reflect the creativity
of each woman in developing her networks (i.e., one woman's networks are not the same
as another's) and the role she plays in keeping her networks together. Furthermore, I use
the concept of social resource management to portray the contingent nature of a woman's
access to resources that are provided by a social network. For example, a woman who
relies upon someone else for a ride to her prenatal appointment cannot fire that person
and then hire another if the person fails to get her to her appointment.

Finally, unlike social capital frameworks in which individuals are portrayed as
hyper-rationalistic entrepreneurs developing resources to maximize profit, I argue that
women's resource management is based upon their tacit knowledge of social networks
established before they became pregnant. A woman does not suddenly develop social
networks when she realizes she is pregnant; she draws upon established resources she is

familiar with to address a new issue in her life. The strategies that women develop to

 

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gain access to prenatal care thus involve steps that they manage strategically based upon

the broad scope of their social networks.

Clinic Personnel's Misconceptions

Clinic personnel, and their organizations, often conceptualize access to services in
terms of socioeconomic issues and ethnicity. This is particularly true of "free," "sliding
scale," and "public" clinics that serve low-income populations, for the programs and
services they offer are structured in terms of working within the limitations of their
clients' financial constraints. For example, clinic personnel perceived transportation, lack
of health insurance and the inability to pay for needed services as barriers that must be
overcome in order to gain access to health care services. As a disproportionate number of
low-income workers who rely upon public clinics belong to an ethnic minority, clinic
personnel often equate belonging to an ethnic minority with being low-income.l
Consequently, many clinic personnel view ethnicity as the primary factor in how low-
income Mexican American women gain access to prenatal care. For example, many
clinic personnel in this study believed that low-income Mexican American women chose
not to work while they were pregnant because they were lazy. Clinic personnel
concluded that since women were unemployed and pregnant they relied upon Medicaid
and thus had access to prenatal care. In such instances, clinic personnel characterized
laziness as a Mexican American trait and perceived laziness, rather than a socioeconomic
issue, such choosing to be a homemaker due to the high cost of childcare, as the reason

Why women were unemployed and using Medicaid.

Using the concept of ethnicity in this manner ultimately does a great disservice to
understanding how low-income populations gain access to health care services for it
reifies what it means to belong to an ethnic minority. For example, typecasting laziness
as a Mexican American trait that explains why women might not work during pregnancy
reifies what it means to be Mexican American. More significantly however, it illustrates
that clinic personnel, and their organizations, fail to understand the fundamental role
resource management plays in shaping low-income, ethnic minorities' access to care. In
doing so clinic personnel fail to look beyond the boundaries of their clinics, the Medicaid
system, and ethnicity to understand, for example, why some low-income Mexican
American women might not work during pregnancy. Consequently, clinic personnel
cannot appreciate the dilemma a low-income Mexican American woman faces when she
realizes that she does not make enough money at her minimum wage job to pay for health
insurance yet combined with her husband's salary she makes too much money to qualify
for Medicaid so she quits her job while she is pregnant. In turn, clinic personnel do not
understand the role family members and friends play as the resources women rely upon to
manage access to prenatal care. Contrary to the beliefs of clinic personnel, this study
argues that women's management of social resources plays a far more significant role

than ethnicity in shaping low-income Mexican American women's access to prenatal

care.

 

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Theoretical Concepts and Critical Approaches to Health Care

The Politics and Economies of Social Resource Management

Using a critical medical anthropology approach, this study shows that the
decisions that low-income Mexican American women make in the process of gaining
access to prenatal care are shaped by the politics and economics of their social resource
mamgement. As other anthropologists have illustrated, a critical medical anthropology
approach addresses

health issues within the context of
encompassing political and economic forces
— including forces of institutional, national
and global scale -— that pattern human
relationships, shape social behaviors,
condition collective experiences, reorder
local ecologies, and situate cultural
meanings. [Baer et al., 1997:27]

Critical medical anthropology frameworks examine the intersection of politics,
economics and social relations within the context of health issues at a variety of levels.
Baer et a1. (1997) propose the four following levels: the macro-social level — involving
the development and expansion of a global economic system; the intermediate level —
examining class and institutional control of health care systems; the micro-level —
referring to the physician-patient relationship and therapy managing groups (Janzen,
1978); and finally, the individual level — examining the patient's experience.

As have other anthropologists (Lazarus, 1997; Rapp, 1999), in this study, I view
the locus of critical medical anthropology analysis on the micro and individual levels. In

doing so, I explore individuals' everyday experiences and examine the social, political

and economic resources low-income Mexican American women draw upon in their

 

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everyday experiences to gain access to prenatal care. The value of this approach to
studying individual experience is that it "regards culturally informed interactions between
social actors and political economic relationships as dialectically related" (Morsy, 1990:
27). I show that women's social resource management is not closed and independent of
other systems or individuals but rather a fluid process in which women draw upon a
variety of resources, and that they use this approach in gaining access to prenatal care.
For example, a woman might find out about prenatal care from an immediate family
member, learn about how and where to enroll in Medicaid from a co-worker, and rely
upon a friend to drive her to her prenatal appointments.

Libbet Crandon-Malamud develops upon this theoretical perspective in her 1991
ethnography, "From the Fat of Our Souls: Social Change, Political Process, and Medical
Pluralism in Bolivia." Her investigation into the reasons people choose or combine
indigenous and cosmopolitan medical systems shows that choice of medical care is not
based on medical efficacy but rather on political concerns. In a medically plural
environment in which people have a variety of medical systems to choose fi'om, Crandon-
Malamud argues that medicine restructures social relations outside of the medical
context. She illustrates this interaction in examining the medical, religious and ethnic
pluralism of Aymara society in Kachitu, Bolivia. Three medical ideologies, or resources,
were available to the Aymara in Kachitu: Aymara medicine — dispensed by indigenous
halers; medicinas caseras — dispensed by mothers in their own home; and cosmopolitan
medicine -— dispensed at the local Methodist hospital. Crandon-Malamud posits that the
boundaries of these three medical ideologies are not concrete, as each of the ideologies

appropriated resources and ideas as needed. Broadly defined in religious and ethnic

terms, the people in Kachitu fall into three groups: Aymara Indians — land-based
peasants excluded from most political and entrepreneurial life; Methodist Aymara —
educated and politically active, they participate in the cash economy; and the Mestizos —
Catholics who, while currently less well ofl‘, were historically socially, politically, and
economically dominant in Kachitu.

For the Aymara people of Kachitu shifting of resources between medical
ideologies and medical beliefs is intricately tied to shifts in social relationships.
Crandon-Malamud argues that ethnic and religious identities are expressed through
diagnostic opinions and the strategies that those identities define (1991 :25). For example,
having no cash and being in an economically precarious position, an Aymara campesina
whose daughter is sick might first seek the knowledge of medicinas caseras before
drawing upon other resources, such as the child's Mestizo godmother, in strategizing her
daughter's treatment. Recognizing that she is unable to pay the physician's fees, the
mother exhausts her knowledge of medicinas caseras before turning to the Mestizo
godmother, for the latter option carries with it its own cost. While the godmother would
be able to facilitate access to the physician at the Methodist hospital, it would create a
social debt between the two women of different religious, ethnic, and economic domains.

Considered within the fluid context of an environment in which a variety of
ethnic, religious, and economic systems co-exist, medical dialogue is used to create
alliances across boundaries that are permeable (1991 :22). The concept of alliance
building is the cornerstone of Crandon-Malamud's argument —— "that medical ideology is
not a single logical construct but rather a series of options that permit the negotiation of

social relations" (1991:139). Crandon-Malamud thus posits that medicine is a primary

10

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resource that people use to gain access to secondary resources that are economic, social,
and political. While recognizing that the negotiation and acquisition of resources are
shaped by economic conditions and class relations, her argument is formulated upon the
notion that individuals actively and consciously select {tom and use the resources
available to them to accomplish their own ends. For Crandon-Malamud this approach is
valuable because

[T]he patient suddenly emerges from this

complex, constantly changing, and

politically charged situation as a kind of

decision maker that most scientists want to

avoid: he is not the Rational Man looking

for medical efficacy; rather, he is a social

and political animal who at times may be

looking for meaning through efficacy which

becomes a validation for some sociopolitical

or economic proposition, but more often is

looking for efficacy through meaning in a
sociopolitical and economic context.

[1991:32-33]

As low-income Mexican American women go through pregnancy and birth they
achieve access to prenatal care through a series of decisions and routines that I analyze as
social resource management. Drawing from Crandon—Malamud's work with regard to the
concept of resource management, I argue that the resources that women draw upon
through social and economic networks — alliance building - form the basis of the
strategies women develop to gain access to biomedical care. Whereas Crandon-Malamud
views medical care as a primary resource, I perceive the social and economic resources
women draw upon, such as networks of family and extended kin, as primary resources

used to achieve access to a secondary resource, specifically, prenatal care.

11

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Whereas Crandon-Malamud's study included patients of varied ethnicity this

study focuses solely upon Mexican American2

women and the resources they manage to
gain access to prenatal care. The participants in this study however, straddle a socially
pluralistic environment similar to that found in Crandon-Malamud's research and my
study's participants, loosely defined, fall into two groups: women seeking prenatal care
and health care workers providing care. Furthermore, the two groups varied greatly in
social class.

Gilbert (1998) presents a model of American class structure that recognizes a
small elite class which draws its wealth from return on assets and a large majority who do
not own capital. His model stratifies the population into six classes based upon typical
occupations and income: 1) the capitalist class (average income, $1.5 million) —
investors, heirs, and executives; 2) the upper-middle class ($80,000) — university-trained
managers and professionals; 3) the middle class ($45,000) — semi-professionals,
craftsmen, and foremen; 4) the working class ($30,000) — low-skill manual labor,
clerical and retail sales; 5) the working poor ($20,000) — lowest-paid manual, retail, and
service workers; and 6) the underclass ($10,000) — unemployed or part-time menial jobs
and public assistance. In this model, the women seeking care in this study belonged to
the bottom two classes — the working poor and underclass. In contrast, the clinic
personnel straddled social classes ranging fi'om the working class to the upper-middle
class.

Broadly defined, women seeking care were pregnant, Mexican or Mexican

American, 18 years or older, on average had attended high school through the 11'" grade,

and were low-income workers.3 Roughly half of the women were single and employed

12

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outside of the home working in maintenance, the food service industry, housekeeping,
and as cashiers. Many married women worked within their homes as homemakers and
their husbands were employed as gas station attendants or worked in construction and
food service. As low-income workers, the women were eligible for state-provided
prenatal care through the Medicaid system.

Clinic personnel in this study varied in social class. While all were employed in
white-collar jobs, their work ranged from that of reception clerks to physicians. Their
annual income subsequently encompassed a wide disparity. Clinic personnel education
levels similarly ranged from a General Education Diploma (GED) to a Medical Degree
(MD). Whereas all of the women seeking care were Mexican American, clinic
personnel's ethnicity was more diverse — "white," Hispanic, and Asian.4 The majority of
clinic personnel were women and roughly half were married. Despite clinic personnel's
varying social class and ethnicity and their interest in continuing to offer health care
services to low-income people, as a group they did not understand the everyday
experiences and challenges facing the low-income Mexican American women they serve.
Often clinic personnel expressed frustration with regard to women they served as they
perceived them as taking advantage of the Medicaid system yet not fully utilizing the
resources, such as mother and infant nutrition programs, that prenatal clinics had to ofi‘er.

While each pregnant woman's goal in this study was to gain access to biomedical
prenatal care, I use Crandon—Malamud's notion of a fluid environment in which
individuals actively and consciously select from and use a variety of resources to
accomplish a specific goal to convey the complexity of low-income Mexican American

women's resource management. For example, in this study a woman might rely upon a

13

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friend to find out about a prenatal clinic, a nurse at the clinic to find out about payment
options, the public health department to enroll in Medicaid, and a co-worker to drive her
to her prenatal appointments. Of fundamental concern is how the woman will pay for
prenatal care — will she use a sliding scale or is she eligible for Medicaid coverage? She
must rely upon either a payment system offered by the clinic or the Medicaid system
administered through the public health department. She similarly draws upon a work-
related economic system by relying upon a co-worker to transport her to and horn her
prenatal appointments.

The economic basis of strategy outlined above is simultaneously influenced by
political power — defined as the ability to modify the behavior of others and enforce a
monopoly of opinion (Crandon-Malamud, 1991). The information the clinic nurse shares
with the woman about payment options is based upon the financial policies of the health
care organization for which the nurse works. The process of enrolling in Medicaid is
similarly structured by institutional guidelines for enrollment at both the public health
department and State levels. Medicaid policy, written by the State's legislature, further
shapes the economic basis of a woman's strategy by determining the services that will be
covered and thus the services to which a woman will have access (e.g., a clinic that
participates with Medicaid, one ultrasound during a pregnancy, and a semi-private
hospital room).

I draw on concepts fiom political economy to analyze low-income Mexican
American women's resource management and recognize that women make decisions and
thus develop strategies to gain access to prenatal care that are shaped by both political

and economic issues. In this context, women's resource management is not a single

14

 

    
 

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news and tom,

logical construct that is closed and independent of other systems but rather one of options
in which a woman's strategy is shaped by social, economic, political and medical issues.
Consequently, the strategies that women develop to gain access to prenatal care thus
involve steps that aremanaged strategically based upon the broad scope of women's
social and economic resources.

Medical organizations, clinic personneL and their clients operate and coexist in a
political and economic environment (Crandon-Malamud, 1991 :32). By examining the
views and behavior of women and clinic personnel as actors and strategists actively
navigating a health care system, I analyze the political economy of resource management
and address the disparity between low-income Mexican American women's and clinic

personnel's views of gaining access to prenatal care.

Conceptualizations of Health Care "Access" and "Barriers"

My study takes up the issue of the process of gaining access to health care — that
is, the decisions women make and the social resources they manage prior to entering a
health care facility. In contrast, research on gaining access to health care has generally
focused on catch phrases such as "health care utilization," "access to health care," and,
more recently, "barriers to care." Each of these terms implies a very different focus of
investigation. "Health care utilization" most often refers to the "kind of services
provided, the site of the service, the purpose of the service, the person or the entity that
provided the service, and the time interval for the service" (Loue, 1999:65). For
example, in a study on rural health, Strickland and Strickland (1996) assessed the use of

preventative health services by low-income minority households in the South. Focusing

15

 

 

 

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on patterns of health care utilization and preventative health care access models, the
authors concluded that pregnant women most often received medical care and children
were more likely than adults to receive physical checkups (Strickland and Strickland,
1996).
The Institute of Medicine as has broadly defined access and barriers to care:

A shorthand term for a broad set of concerns

that center on the degree to which

individuals and groups are able to obtain

needed services from the medical care

system. [1993:4]

Whether opportunities for good health

outcomes are systematically denied to

groups in society. [1993:4]
Research on "access to health care" and "barriers to care" has focused on issues ranging
from elements of access, such as availability, accessibility, accommodation, affordability,
and acceptability (Loue 1999:68), to pathway models for seeking care (Chrisman, 1977;
Suchman 1965; Weller, 1997), to studies that address factors that affect service use as
barriers to health care (Estrada et al., 1990; Kasper, 2000; Trevino et al., 1991). Judith
Kasper highlights a recent trend in health care research on access and barriers to care as
she points out in her discussion of "Health Care Utilization and Barriers to Health Care,"
that access to care and barriers to care are often used interchangeably for it reflects a

prevalent trend in policy oriented research of the biomedical health care system —

"Barriers provide targets for policy intervention" (2000:326).

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Barriers to Entry
Growing interest in research on access to health care and barriers inhibiting access

to care has focused on three aspects of health care utilization: 1) barriers to gaining entry
to care; 2) barriers in the process of receiving care; and 3) barriers from the consumer's
perspective (Kasper, 2000). In this framework, access is conceived of as a two part
model in which health care policy lays the foundation for access and characteristics of a
population, usually an "at risk" population, determine an individual's use of the system.
As Loue (1999:68) explains,

The health care delivery system consists of

two primary elements: (1) resources, such as

labor, capital, personnel, and materials, and

(2) organization, which refers to the process

of entering the health care system and

receiving treatment and to the structure of

that system. The characteristics of the

population at risk encompass the enabling,

predisposing, and need factors that

constitute the individual determinant of

utilization.
Working within Loue's two-part model of access, "enabling" factors refer to the resources
available to an individual for the use of services, "predisposing" factors are an
individual's demographic characteristics, and "need" factors are determined by the extent
or degree of an individual's illness.

The aforementioned model focuses on aspects of the individual that determine

use, deflecting attention from the process involved in gaining access to health care
services. For example, Loue's two part model might suggest that an individual is inclined

to use, or not use, a specific health service based upon demographic characteristics such

as their age or ethnic background. In contrast, I argue that political and economic aspects

17

 

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of an individual's social resource management are a more significant indicator of whether
or not she will use available health care services. By shifting the focus to women's social
networks and resume management my study examines how women enter the health care
system — the active process of gaining access to prenatal care grounded in everyday
experiences — rather than presuming that their entrance is determined by a fixed set of
individual predisposing factors.

Many health organizations conceptualize "access" as "availability" (Lone, 1999).
In this study however, I draw a distinction between the availability of and access to health
care. I use availability to describe a health service in relation to patients who are eligible
for care. Studies of availability focus on measures such as numbers of insured patients;
numbers of physicians, hospital beds, and hospitals per capita; and similar yardsticks as
though access to medical care is equitable. I define access to medical care as a process in
which a woman is engaged in seeking care, in relation to her particular situation,
including finances, insurance, eligibility for a given health service, household decision
making, and transportation.

Research on how "populations at risk" gain access, or entry, to health care
services has often focused on the process of seeking health care, specifically, "pathway
models for seeking care" in which researchers diagram the steps individuals take in
obtaining needed medical care (Chrisman, 1977; Igun, 1979; Suchman, 1965). Research
on pathway models for seeking care have conceptualized and evaluated disease and
access to health services in terms of biomedical care. Suchman (1965), for example,
proposed a five-stage model to explain the disease process in which a person first

experienced a symptom of a disease, identified himself as sick, established needed

18

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biomedical care, identified himself as a patient, and, finally, recovered from the disease.
At the same time however, Suchman recognized that "an individual's response to medical
care is influenced by various group relationships at the community, social group, and
family levels" (Loue 1999:69).

Working upon this premise other social science researchers, anthropologists in
particular (Crandon-Malamud, 1991; Janzen, 1978), have recognized the significance of
individual and group relationships that are intricately entwined with economic and
political issues at various societal levels. F ernandez-Kelly (1983), Roseberry (1992), and
Wolf (1982), highlight this theme in their respective discussions of household dynamics
in the context of historical, political, and economic relationships to the community.

In this vein, studies of barriers to entry to care have focused on characteristics of
individuals and their social environments, such as poverty and socioeconomic status
(Bushy, 1990; Hunter et al., 1991; Wojtusik and White, 1998), and ethnic minorities and
culture (Chang and Fortier, 1998; Harmon et al., 1996; Scribner and Dwyer, 1989).
Kasper (2000:327) asserts however, that "[D]espite skepticism about the ability of health
services to significantly intervene in the relationship [between poverty and poor health],
the extent to which poverty or low socioeconomic status contributes to problems in
obtaining care has been a major focus of access studies and remains a key test of health
system equity."

In assessing how barriers to care inhibit individuals' access to health care services
much attention has been given to ethnic minorities, specifically Latinos, and culture
(Browner, 1989; Estrada et al., 1990; Molina and Aguirre-Molina, 1994; Moore and

Hepworth, 1994; Solis et a1, 1990; Trevino et al., 1991; Valdez et al., 1993). "The use of

19

race as an explanatory variable in health services research has been challenged recently
on the grounds that it often firnctions merely as a proxy for other characteristics,
primarily socioeconomic status" (Kasper, 2000:328). LaVeist (1994) for example, asserts
that the concept of race is poorly understood because it lacks conceptual clarity.
Consequently, comparisons of health indices for racial or ethnic groups in the United
States are often presented without stratifying or accounting for socioeconomic conditions
(Blanton and LaVeist, 1996). Williams and Collins (1995:366) argue however, that
researchers must continue to address race and ethnicity in examining the inequity of
health care access because racial and ethnic discrimination persist in the health care

system.

Ethnicity and Health Research

Much of the literature on ethnicity and health care reflects researchers' interest in
minority populations' use of alternative or indigenous sources of care. Employing a
medically pluralistic approach (Janzen, 1978), researchers have worked upon the premise
that ethnically diverse populations will seek care from both a provider specific to their
ethnic culture as well as a biomedical care provider (Beckerleg, 1994; Janzen, 1978;
Rehbun, 1993).

Efforts to understand what is traditionally referred to by the medical community
as "complementary" or "alternative" medicine have motivated many researchers to
examine ways in which "folk" medicine and biomedicine can be integrated in everyday
practice. As Elvia Krajewski-Jaime explains in her chapter on "Folk Medicine Among

Mexican American Families" in "Rethinking Ethnicity and Health Care" (1999), clinic

20

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personnel should consider cultural factors, such as the belief in folk medicine, that shape
the ways in which Mexican American families deal with the health problems of their
children. She further argues that by attempting to integrate "folk beliefs" and
biomedicine the health care practitioner can enhance the intervention process. One
example Krajewski-Jaime gives to illustrate how this might be achieved is to keep an
infant or child partly covered during a physical examination in the effort to reduce the
mother's fears about mal aire (1999:259).

In the literature it appears that two ramifications have burgeoned out of
researchers' interest in the interplay of alternative medicine and biomedicine. One has
been the recognition that "Hispanics" in the United States are a heterogeneous population
that has a diverse cultural, political and historical background (Blea, 1988; Krajewski-
Jaime, 1999; Padilla, 1985; Portes and Bach, 1985). As a result, political and economic
issues specific to different "Hispanic" groups have come to the forefront of understanding
how and why people choose particular clinic personnel. For example, the role that
gender, class and nationality play in Mexican and Mexican American women's access to
US. biomedical health care illustrates socioeconomic aspects of women's choice of
medical systems on the U.S.-Mexico border (Guendelrnan and Jasis, 1992; Estrada et al.,
1990; Higginbotham, 1990; Moore and Hepworth, 1994; Solis et al., 1990; and Trevino
et al., 1991).

On the other hand, efforts to achieve the practical integration of folk medicine and
biomedicine seem to be caught in a backlash of sorts in which folk medicine is perceived
as a barrier to biomedical health care (Krajewski-Jaime, 1999:252). This view is

supported in particular by biomedical clinic personnel who perceive folk remedies as

21

 

 

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hazardous to patients' health Most significantly however, clinic personnel's perception
of folk medicine as a barrier has spurned a plethora of investigations into research on
barriers to health care in general and why ethnic minorities might prefer folk or
alternative medicine to biomedicine. For example, in examining access to biomedical
health care on the U.S.-Mexico border, Guendelrnan and Jasis (1992) argue that
socioeconomic factors and Mexican women's attitudes towards U.S. obstetrical care
determine their choice of utilizing Mexican or US health care services. Higginbotham
(1990) tempers this definitively socioeconomic argument in his examination of Mexican
Americans' use of curanderos and biomedical health care services in which he posits that
Mexican American use of a curandero is related to cultural orientation and dissatisfaction
with biomedical care, but not to income and availability of biomedical services. In
contrast, Estrada et a1. (1990) identified a number of factors, such as lack of health
insurance, the high cost of health care, low income, and lack of transportation, as barriers

that affect Mexican Americans' use of biomedical health care services.

Cultural Competency

Health care practitioners' growing awareness of their patients' ethnicity and the
role complementary or alternative folk medicine plays when providing health care
services has burgeoned into a standardized field of cultural competency training.
Whereas folk medicine was previously perceived by biomedical health care practitioners
as dangerous and thus a barrier to health care, clinic personnel are now being urged to
view folk medicine as a positive resource that should be capitalized upon when treating

ethnic minority populations (Krajewski-Jaime, 1999:252).

22

 

 

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Training courses in cultural competency have for the most part, been health care
organizations' main venue in helping clinic personnel — from intake workers to
physicians —- to re-conceptualize folk medicine as a positive resource (Foard, 1995;
Rorie et. al., 1996; Salimbene, 1999; Zayas et. a1, 1997). Defined as "[t]he knowledge
and interpersonal skills that allow clinic personnel to understand, appreciate, and work
with individuals from cultures other than their own" (McManus 1988), cultural
competency training is based on research that assesses demographic and health status
statistics for a given ethnic population in relation to the role of culture in health care. For
example, in their article "Meeting the Health Promotion Needs of Hispanic
Communities," Delgado et al. (1995) state that compared to other ethnic groups in the
United States, Hispanics are less likely to own a home, are less educated, more inclined
to live in poverty, and in general, have a lower health status than the non-Hispanic
population. Among other solutions, the authors argue that clinic personnel should receive
cultural competency training to understand the impact of culture and language on
Hispanic health.

Research, and consequently, training in cultural competency has had an
unintended side effect in that efforts to recognize the ethnic diversity of populations *
seeking health care lmve led to the inadvertent reification of what it means to belong to a
particular ethnic group. In response to the unequal status of health and health care access
for ethnic minority populations, The Office of Minority Health, the US. Department of
Health and Human Services and other health science researchers have undertaken the task
of documenting the health status of ethnic minority populations in the United States

(Xueqin Ma and Henderson, 1999).

23

 

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The findings in these task force and research reports have been intended to
highlight the health care gap between ethnic minorities and whites, improve access to
health care, and raise cultural awareness through cultural competency training; however,
much of the research (Davis and Voegtle, 1994; Erzinger, 1999; Franke and Ohene-
Frempong, 1999; Jones-Saumty, 1999; Penn et al., 1999; Xueqin Ma and Henderson,
1999) has reified health issues and what it means to belong to minority ethnic groups by
boiling complicated health issues and diverse cultural "characteristics" down to the most
prevalent illness and ethnic beliefs or traits. In many ways it is not surprising that health
researchers have boiled ethnic differences down to a few essential variables as this fits
with the biomedical model of reducing a complex series of factors so that they can be
plugged into the decision making model of health access and disease.

The American Medical Associations' guide for primary clinic personnel titled,
"Culturally Competent Health Care for Adolescents" (Davis and Voegtle, 1994) clearly
illustrates this point. Chapter 5, "Portraits of Major US. Racial/Ethnic Groups," is
intended to give clinic personnel an overview of demographic, socioeconomic, and
cultural beliefs and practices for the four major ethnic minority groups in the United
States — African American, Asian, Hispanic, and Native American. The authors do
suggest that not all of the information in each section applies to all people in each ethnic
group however the portraits are intended to highlight "common cultural elements for
these groups" (Davis and Voegtle, 1994:39). Although the section on the Hispanic
population in the United States recognizes that "Hispanic" refers to a diverse group of
people from a variety of Latin American countries, the authors' discussion of "Hispanics'"

beliefs about health and illness are shaped by the common belief that poor health, and

24

 

 

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events in their lives in general, "result from luck, fate, or other powers beyond the
individual's control" (Davis and Voegtle, 1994:52). The authors thus suggest that
recognizing this aspect of Hispanic culture will aid clinic personnel when interacting with
Hispanic patients:

This may be helpful in some cases, for

example, when a family views a youth with

a chronic disability as not being responsible

for his or her condition. However, it may

lead to more passive participation in

treatment or healing. [Davis and Voegtle,

1994:52]

The goals of such guides are valuable in that they are the most readily accessible
resources in educating clinic personnel about the significant role cultural beliefs play in
their interactions with patients. Unfortunately, researchers' efforts to disseminate a vast
and diverse amount of data about ethnic populations have led to the reification of ethnic
groups — diabetes and homicide are viewed as African American issues; early sexual
activity and teen pregnancy are viewed as Hispanic issues; and alcoholism is viewed as a
Native American issue (Xueqin Ma and Henderson, 1999). Consequently, the fluidity of
cultural beliefs and diversity of socioeconomic, demographic and health data are posited

as fixed representations of whole populations rather than beliefs, characteristics, and

health issues specific to individuals.

25

 

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Other Conceptual and Theoretical Issues
Gender Centered Approach

Contemporary work in ethnography and other social sciences shows that recently
highlighted dimensions of society need to be taken into account to understand the
everyday pursuit of health and healing. One of these dimensions is gender. Within social
science, and more specifically the field of anthropology, there has been a growing
awareness that gender must play a central role in ethnographic analysis, addressing
political and economic aspects of health. Growing advocacy for the centrality of gender
in understanding the everyday pursuit of health and healing is illustrated by social
scientists, such as Linda Whiteford (1996), who argue that gender must take center stage
in the analysis of health and illness. Whiteford posits that rather than adding gender to
the list of variables to be considered in analysis, the culture and political economy of
health must be situated within a feminist approach fiom the start (see also di Leonardo,
1991 on the centrality of gender in anthropological analysis). Consequently, she calls for
the "gendering" of political economy in anthropology to understand the processes
underlying the social production of health (1996). In Whiteford's view, the goal of a
gendered perspective of a political economy of health is to create an intersection of
global, political, and economic interactions and local systems, communities, and actors
— contextualizing local cultural, social, political, and economic processes within a
historical perspective. Following her argument that health is socially produced, the
dimension of gender thus sheds light on ways in which the social construction of gender

roles restrict women's access to resources. As a result, a gendered approach to health

26

 

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illustrates that poor health is not necessarily the fault of the individual, but rather, due to

limited access to resources.

Tacit Knowledge: Negotiating Access to Health Care Services

Pregnancy and birth are events that are between commonplace and unique
everyday experiences. As such, women draw upon tacit, or practical, knowledge (on tacit
or practical knowledge see, Giddens, 1979) as well as creating new strategies to manage
pregnancy and birth. Health care workers similarly negotiate their interactions with
patients (Martin, 1987), drawing upon preconceived notions and tacit knowledge of both
the health care organization they work for and the people who are attempting to gain
access their services.

My interpretation of women's negotiation of health care access and health care
workers' views on providing access to low-income Mexican American women is
grounded in a practice perspective (Bourdieu, 1980). A practice perspective allows me to
center the locus of my investigation on the actor, personhood, and everyday experiences.
Consequently, by examining the data from a theoretical approach grounded in practice I
analyze how women manage resources in the everyday experience of negotiating child
care, working both in and outside of the home, dealing with social and economic issues
of unemployment, and living in extended family households. Furthermore, this
theoretical approach facilitates the examination of the goods and services of social
economies, such as childcare, transportation, and extended family networks that women

use in managing access to health care services. Thus, a practice approach conveys the

27

 

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notion of a wormn who actively manages a variety of resources in negotiating access to
health care.

I draw on this approach to examine the views and behavior of clinic personnel as
actors and strategists in facilitating low-income Mexican American women's access to
prenatal care. Analyzing clinic personnel's perceptions of low-income Mexican
American women's expectations of and beliefs about the US. biomedical system shows
how the politics and economics of resource management influences clinic personnel's
understanding of health care access. As illustrated in later chapters, investigating clinic
personnel's perceptions of low-income Mexican American women's access to health care
in the context of clinic personnel's daily clinical experiences, including waiting room
interactions, intake interviews, and consultations, evidences that the process of gaining
access to health care services articulates with clinic personnel's preconceived notions of
what it means to be poor, female, and Mexican American, as well as with the gender and
ethnicity of clinic personnel themselves.

A practice approach portrays the notion of women and clinic personnel actively
navigating a health care system as well as how barriers related to gender, ethnicity, and
political economy influence clinic personnel's perceptions of access. By revealing how
institutional structures, such as types of health care services, payment options, and
support services that are offered to, or withheld from women, and everyday experiences
influence low-income Mexican American women's social resource management in the
process of gaining access to prenatal care, this study provides an understanding of two
aspects of access: as a process that women manage individually and, as perceived by

clinic personnel, a process that women go through effortlessly in a routine way.

28

 

 

 

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Endnotes

 

' According to the State of Michigan Department of Social Services, in 1995 172,960 families in Michigan
received assistance from the Aid to Families with Dependent Children (AFDC). Based upon ethnicity, of
these total recipients 42.8% were white, 51.7% were back, 0.4% were American Indians, and 2.9% were
Hispanic. As Fayyaz Hussain points out in his research report, "Social Welfare Reforms in Michigan:
Intent and Implications for the Poor" (1996), the 42.8% of white AFDC recipients is significantly less than
their proportional population of 82.4% in Michigan. Conversely, the 51.7% of black AFDC recipients are
much larger than their proportional population of 13.5%. Hussain thus concludes that "an out of proportion
population of blacks, Native Amaicans, and Hispanics in Michigan are living in poverty . . . and that this
uneven poverty leads to an uneven number of welfare recipients across the above-mentioned population
subgroups” (Hussain, 1996z4).

2 I use the term Mexican American to refer to those who belong to an ethnic group also known by various
other names, including "Mexican" and "Chicano," and more broadly, "Latino" and "Hispanic."

3 In this study, low-income is defined in terms of the State of Michigan Family Independence Agency's
1997-1998 guidelines in which family income and number of children are used to calculate eligibility for
Medicaid services. For example, a family of three with a monthly income of $1,623.00 or less is
considered low-income and thus qualifies for Medicaid coverage. I chose to use the Family Independence
Agency‘s guidelines for defining low-income as the baseline in this study because it provides for parity
between the three clinics in which I was collecting data

' These ethnic categories are based upon the US. Census Bureau's standardized classification system.
While conceptually problematic, I use these categories because they reflect the system of ethnic
classification that clinic personnel refer to when interacting with patients who belong to an ethnic minority.
See Martin N. Marger's book, "Social Inequality: Patterns and Process" (1999), for an in depth discussion
of the conceptual problems with this system of racial and ethnic classification.

29

 

 

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Chapter 2: Methods

The participants' views and experiences analyzed in this dissertation were drawn
from 15 months of ethnographic research conducted in Lansing, Michigan throughout
1997 and 1998. Data were collected through participant observation and open-ended
interviews in three OB-Gyn clinics that serve low-income women —— a Latino community
health center clinic, a public health clinic, and a hospital based clinic. Data for this
research were collected in two phases. The first phase involved participant observation
and open-ended interviews with low-income Mexican American women who lived in the
Greater Lansing area, addressing the strategies women developed to gain access to
biomedical health care during pregnancy and birth. Phase two focused on investigating
clinic personnel's perspectives of low-income Mexican American women's access to
health care during pregnancy and birth using these same methods.

The three clinics in which I collected data were chosen both because of their
similarities and their differences to each other. While all three were biomedical clinics
that served low-income women, each was structured differently by the parent
organization. For example, the community center clinic was housed on the first floor of a
Latino community center that sponsored a wide variety of services ranging from after-
school childcare to food subsidy for agricultural migrant farm workers to Alcohol
Anonymous programs. While the health clinic was a department of the Latino
Community Center it was a self-contained unit with its own director and staff. In keeping
with the mission of the Community Center, however, the clinic was not solely limited to

OB-Gyn care. In fact, the clinic set aside only one morning each week for OB-Gyn care.

30

 

 

 

0‘:

a:

The rest of the week was dedicated to general practice, a pediatrics clinic, and, in the
summers, a mobile migrant health clinic which visited local migrant farm worker camps
one evening each week.

The Public Health Clinic, housed in the wing of a large Public Heath Department,
and the Hospital Clinic, located in a modular unit in one of the hospital's parking lots,
were similar to the Latino Community Center Clinic in that they were also departments
within larger organizations. Each clinic, however, acted as a self-contained unit with its
own director and stafl'. Unlike the Latino Community Center Clinic, these clinics

practiced solely obstetrics and gynecology every day of the week.

Sampling Stratggies

The participants in this study were selected using non-probability sampling,
specifically judgement and opportunistic sampling methods. I chose the research settings
and the participants to deliberately reflect the experiences of low-income Mexican
American women using prenatal care. The three clinics in which data were collected
were intentionally chosen to represent the variety of biomedical prenatal care available to
low-income workers in the greater Lansing area: public, private, and community center
funded clinics. As I discuss below, both the women seeking care and the clinic personnel
were selected to participant in this study based upon the virtue of their status as either
low-income Mexican American women seeking care or clinic personnel working in the

prenatal clinic.1

3]

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Criteria for Selecting Women

Women seeking prenatal care qualified to participate in this study based upon the
following criteria. The women had to be: 1) pregnant or have given birth within the last
three months; 2) at least 18 years or older; and 3) of Mexican or Mexican American

descent. I invited women who met these criteria to participate in the following manner.

Latino Community Center Clinic

Using the clinic appointment schedule, I approached women in the waiting room
to discuss my study, find out if they were interested in participating, and determine if
they met the aforementioned selection criteria. If women indicated they were interested
in the study I obtained their informed consent to participate.

I approached every woman on the clinic appointment schedule who was in the
waiting room and had a Hispanic first or last name — usually 5 to 7 women each day. Of
the womenI approached, on average, 1 to 2 women would decline to participate because
they were busy filling out clinic paperwork, had to watch their children, or simply were
not interested in talking with me. On any given day, roughly one third of the women on
the schedule did not meet the selection criteria, primarily because of their age or
ethnicity. I usually conducted interviews in the waiting room while women were waiting

to see the physician.

32

 

 

 

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Public Health Clinic

Women were identified by the clinic Charge Nurse as potential participants for
my study. Based upon the following criteria, each week the Charge Nurse would review
patient charts and insert a copy of the consent form for my study into the files of patients
she believed to be Hispanic because: 1) their first or last name appeared to be Hispanic;
2) they checked "Hispanic" on their intake sheet; 3) she had first hand knowledge of the
woman. The consent form for my study, copied onto bright orange paper so it would
stand out fiom other documents in the patient's chart, served as a flag to the Clinic Nurse
who worked with the patient. The Clinic Nurse would explain my study and then ask the
patient if she was interested in talking with me. If the woman agreed, the Clinic Nurse
escorted her to the coffee/education room where I was waiting.

Upon greeting the patient I discussed my study with her, found out if she was
interested in participating, and reviewed the aforementioned selection criteria. If the
woman met all of the selection criteria and was interested in my study, I then obtained
her informed consent to participate. Interviews were conducted in the coffee/education
room in between the patient's assessment interview with the Clinic Nurse and her
physical exam with a nurse practitioner or physician.

While the same Charge Nurse was responsible for identifying potential subjects in
the study by placing the consent form in a patient's file, all five of the Clinic Nurses were
involved in recruiting potential participants. As a result, there was some continuity in the
initial selection process whereas I had little control over the way in which the Clinic
Nurses were presenting my study and thus recruiting participants. Regardless, the major

drawback to the overall process was that I had very little control of the selection and

33

HI

recruitment process. Consequently, I was unable to assess what percent of women who
came in to the clinic on a given day were potential subjects, how many were overlooked
as potential participants, what percent declined to participate, and, finally, why they

declined to participate.

Hospital Clinic

Similarly to my approach at the Latino Community Center Clinic, I used the clinic
appointment schedule at the Hospital Clinic to identify women who qualified as potential
subjects in my study. Usually, I approached women in the waiting room to discuss my
study, find out if they were interested in participating, and determine if they met the
aforementioned selection criteria. If women indicated they were interested in the study I
invited them to join me in an empty exam room where I conducted the interview after
obtaining their informed consent to participate. About a third of the time, however, I
interviewed women in their exam room in between their visit with the nurse and the
physician.

I approached every woman on the clinic appointment schedule that was in the
waiting room and had a Hispanic first or last name — usually 3 to 4 women each day. Of
the women I approached, on average, I to 2 women would decline to participate for the
reasons listed above. On any given day, roughly three fourths of the women on the

schedule did not meet the selection criteria, primarily because of their age or ethnicity.

34

.n

 

Cri

, s3
--

“tie

“it I

Criteria for Selecting Clinic Personnel

All of the clinic personnel at each of the three clinics were eligible to participate
in this study as I was interested in interviewing front desk workers, receptionists, nurses,
and physicians to elicit perspectives of women's access to prenatal care at each step of the
process. My goal was to interview a minimum of two receptionists, two nurses, and one
physician at each of the three clinics. Since I had been in the clinics conducting
participant observation and interviews with patients, the majority of clinic personnel
knew me and were familiar with my research. I usually would approach clinic personnel
in passing or stop by their offices to ask them if they were interested in participating in
my study; thus, I set up interviews in advance as clinic personnel schedules permitted.

At the time of the interview, I re-explained the purpose of my research, confirmed
the subject's interest in participating, and then obtained their informed consent to
participate. Interviews with clinic personnel were conducted either in clinic personnel's
offices or in a quiet, relatively private area, such as a corner of a hallway or vacant office
space, at each of the three clinics. On any given day roughly half of the clinic personnel
were absent fiom the clinics due to rotation schedules and part-time employment. Only
two of the 19 clinic personnel I approached declined to participate — one because she

was too busy and the other because she did not want to "be in a study."

35

 

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Dan-ended Interviews
Phase I

In Phase I, I conducted 27 semi-structured interviews with open-ended questions
with women in the three clinics. Bernard (1988) indicates that interviewing, combined
with direct observation, is a useful method for eliciting reliable data. Interviews were
loosely structured based upon a written list of questions and topics that I wanted to cover
in a particular order in each of the interviews (see Appendix A). After completing two or
three interviews, I modified the interview guide to include questions about gaining access
to Medicaid as this seemed to be, and continued to be, a major theme in women's
discussions.

As discussed above, prospective subjects were first identified by name, as listed
on clinic appointment schedules, and then asked to identify their ethnicity at the start of
the interview. Interviews were conducted in the waiting room of the community center
clinic, in the education and coffee room at the public health clinic, and in an exam room
or the social worker's office at the hospital-based clinic. In these interviews I elicited
women's experiences and explanations for the kinds of health care services they were
seeking or sought during pregnancy and childbirth2 More specifically, I noted whether
the women reported that family and fiiends had offered advice, and whether husbands
and other family members had participated in making decisions either by facilitating or
constraining the process.

I focused on four sets of questions in interviews with women. The first addressed
demographic issues such as place of birth, marital status, and number of children. The

second set of questions addressed employment and education. The third set investigated

36

l’ln

.l-fl

what kinds of health care services women used, their reasons for using specific services,
how constraints such as finances, insurance policies or lack thereof, and transportation
influenced their decision making process, and any services women wanted to use but
could not. The final set of questions, which were Open-ended, focused on women's
expectations about labor and birth and, when applicable, how women expected their
upcoming labor experience to be different or the same as in previous pregnancies.

Interviews took roughly 35 to 70 minutes, depending upon the participant.

Phase II

In Phase II of my research, I conducted open-ended interviews with health clinic
personnel at each of the three clinics. Again, interviews were loosely structured based
upon a written list of questions and topics that I wanted to cover in a particular order in
each of the interviews (see Appendix B). After completing a couple of interviews, I
modified the interview guide to include questions about why clinic personnel thought
women might not be working during pregnancy as the issue was raised often in the
course of the interview.

Women come into contact with a variety of different health care workers, or clinic
personnel, in the process of gaining and then managing their access to biomedical health
care. In light of this, I interviewed front desk intake workers and receptionists, nurses,
and physicians to elicit their perspectives on women's access at each step of the process. I
focused interviews with intake workers and receptionists on their perceptions of
accessibility of health care at their clinics, their experiences in admitting low-income

Mexican American women, and their explanations about barriers to health care.

37

:I_)

I

Interviews with nurses and physicians similarly focused on their perspectives on the
accessibility of health care at their respective organizations, and, specifically, clinic
personnel's experiences with low-income Mexican American women in health care
settings. A minimum of two intake workers or receptionists, two nurses, and one
physician were interviewed at each of the three health care organizations. I conducted a
total of 15 interviews. Interviews at the community center clinic were conducted in
whatever quiet space could be found, usually two chairs placed in a quiet corner of the
hall. In contrast, interviews at both the public health clinic and the hospital-based clinic
were conducted in clinic personnel's respective offices or in an empty office or
conference space.

Similar to the format used in Phase I, my interviews with clinic personnel began
with demographic issues and then addressed education and employment, investigating
how and why clinic personnel came to work in a health care profession. The third set of
questions elicited clinic personnel's perspectives on issues ranging fiom why they thought
that women sought prenatal care to how women found out about and chose a clinic. The
fourth and final set of questions, which were open-ended, investigated clinic personnel's
perspectives on barriers they perceived women faced in gaining access to health care,
such as having private (commercial) vs. public (Medicaid) health insurance, provider-
patient interactions, and language and "cultural" barriers.

I had anticipated that interviews with women seeking care would be conducted in
Spanish, however, the majority of the women I interviewed either spoke English as their
first language or did not speak Spanish. In all, I conducted only two interviews in

Spanish with women who had moved to the Lansing area from Mexico a few months

38

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prior to our meeting. I conducted all of the interviews with clinic personnel were in
English as well, although many of the clinic personnel spoke fluent Spanish.

I took extensive handwritten notes during the interviews with both women
seeking care and clinic personnel. I was reluctant to use a tape recorder in interviews
with pregnant women for two primary reasons: 1) it was difficult to achieve reasonable
sound quath in the waiting room of the community center clinic; and, 2) the tape
recorder seemed to reinforce the formal context of the interviews conducted at both the
public health clinic and the hospital based clinic. While all of my interviews with clinic
personnel at each of the clinics were conducted in either clinic personnel's offices or
"private" areas, I chose not to tape record these interviews for the similar reason that it
promoted a formal or official air. Many of these interviews began with clinic personnel
vocalizing their institutions' "formal rap." Only after we had discussed health care access
at an abstract or impersonal level would they begin to speak about these issues in the
context of their own organizations and personal experiences. Consequently, I used
shorthand note taking to record data collected in interviews with both women seeking
care and clinic personnel. I then transcribed my handwritten notes after the interview. In
a separate field journal I recorded contextual observations about interviews as well as my

own thoughts and feelings about my interview experiences.

Participant Observation
While I conducted participant observation at all three of the clinics in both phases

of this research, the nature of my participant observation greatly varied at each

organization. As previously discussed both the physical and administrative structure of

39

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each clinic once again influenced my data collection. In its most firndamental form
participant observation in the first phase of the research involved: sitting in waiting
rooms observing women as they registered for their appointments, occasionally
translating for Spanish speaking women during their nurse intake interviews when their
"translators" did not show up, and, in a few instances, observing actual physical exams
when invited. While all of these activities took place at each of the clinics, both my
interview location and how I was incorporated into the organization fundamentally
influenced my participant observation. Since interviews at the community center clinic
were conducted in the waiting room, due to the tight quarters of the exam rooms,
participant observation encompassed informal discussions with women about current
issues, their marriages as well as my own, their children, my reproductive history, works
issues, etc. In comparison, participant observation at the public health and hospital based
clinics was for the most part limited to time I specifically set aside to sit in the waiting
rooms and observe.

Participant observation in Phase II of this research was similarly influenced by the
physical and administrative structure of each clinic. Coupled with the highly routinized
flow of patients through the clinic and the locale of my interviews (the coffee/education
room), participant observation with clinic personnel at the public health clinic was
limited to informal conversations with staff in the coffee/education room, the central
nurses' station, and the hall way of the clinic. Participant observation at the hospital
based clinic was similarly structured in that my interactions were limited to informal

conversations with clinic staff at either the nurse/physician station, as I waited between

40

a“.

interviews, and the reception area as I reviewed the physicians' schedules for prospective
participants.

While my goal at all three of the clinics in this phase was to observe interaction
between clinic staff and patients as well as interaction among receptionists, nurses,
physicians, and other staff members, participant observation at the community clinic
encompassed far more than it did at the other two clinics. Again, this was greatly due to
the physical and administrative structure of the clinic. Not only was the clinic short on
space, they were short-staffed as well. My very presence in the clinic, combined with the
head nurse's knowledge of my undergraduate coursework in medical microbiology made
me a prime volunteer. Consequently, informal discussions in the nurses' station were
often co-opted with requests for secretarial, preparatory, and laboratory help. As I filed
charts in behind the reception desk, I often observed discussions about payment plans,
appointments, and referrals between receptionists and patients. Interactions between
nurses and patients were observed as I laid out instruments needed for exams. Similarly,
as I centrifuged blood samples and filled out the corresponding lab paperwork, I observed
interactions between receptionists, nurses, physicians and social workers.

Data collected through participant observation were recorded in a two-stage
process. While in the waiting rooms I would jot down notes about my observations and
conversations with people as unobtrusively as possible. I would similarly take notes
about my discussions and activities with clinic personnel. 1 would then flesh out and

develop these notes in a field journal, which I kept on my computer at home.

41

Data A:

Qualita

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items

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Data Analysis
Qualitative Data
Analysis of data collected from open-ended interviews and participant
observation encompassed a multi-step process that began with review of transcribed
interview notes, my journal observations about interviews, and my participant
observation journal — all of which were kept on my computer. The first step in this
process involved searching the data for themes to develop analytical categories (for
example, how women found out about prenatal clinics). Following a process of
qualitative data analysis explained by Jennifer Mason in her article, "Linking qualitative
and quantitative data analysis" (1994), I grouped themes identified in the data into two
analytical categories: descriptive and conceptual. Descriptive categories were a list of
main topics in which I was interested. For example:
How women chose a prenatal clinic:

0 Family

0 Friends

- Clinic/hospital service

- School

0 Other

0 Not sure
Conceptual categories were intended to identify the theoretical perspectives about
women's resource management (for example, data that illustrated the intersection of
women's reliance upon both co-workers and family members in developing strategies to
gain access to prenatal care).

I then used the descriptive and conceptual categories to index the data in each of

the three formats for both phases of the study. This process involved labeling the data

with the key terms from each category so that I could then search and retrieve

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information based upon common themes. The primary advantage of this system was that
while it allowed me to search for common themes through out all of the data sets,
individual interviews and journal entries were left intact thus nuintaining the raw

ethnographic data of each entry.

Quantitative Data

While open-ended interviews with women seeking care and clinic personnel were
intended to elicit primarily qualitative data, some quantitative data were collected. For
the most part quantitative data were comprised of demographic information, such as
place of birth, marital status, number of children, which addressed household
composition. Questions in which I asked women about how they found out about clinical
services, and correspondingly, in which I asked clinic personnel about how they thought
women found out about clinical services, elicited responses that were quantifiable. For
example, 6 women said they found out about a clinic from their mothers, 4 from fiiends,
and 5 from school. In order to display these data, I present them in a pie chart or graph
format based on data from the open-ended interview schedules entered an Excel spread

sheet.

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Endnotes

 

' Potential participants in this study were drawn from a pool of women seeking care and clinic personnel
with whom I had contact in a clinical setting. I chose to recruit subjects in a clinical setting, as the goal of
my study was to discuss the strategies women employed to gain access to biomedical prenatal care. As a
result, the clinic and the clinic context bound the process of selecting participants and my data. One
limitation of this methodological approach is that I am unable to answer some questions about the
significant role the household plays in shaping women's management of social resources in gaining access
to prenatal care.

2 The goal of the interviews was to discuss the decision making process and social resources women drew
upon in gaining access to the prenatal clinic. Discussion focused on women's decisions and actions that
preceded their arrival at the clinic in contrast to decisions they made about their care within the clinic. In
interviews with both women and clinic personnel I made a point of explaining that the interview was not
about evaluating the quality of care provided at the clinic.

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Chapter 3: The Participants and Their Settings

The three clinics in this study reflect the array of different types of prenatal care
for low-income pregnant women (a Latino Community Center Clinic, a Public Health
Clinic, and a Hospital Clinic). While all three were biomedical clinics that provided
obstetrical and gynecological care to low-income women, each was structured differently
by their parent organization. For example, the Latino Community Center Clinic and the
Public Health Clinic both dedicated specific times each week for their prenatal clinics,
whereas the Hospital Clinic saw prenatal patients five days a week. While all three of the
clinics were units of larger organizations the Latino Community Center Clinic and Public
Health Clinic, which were each housed in the same building as their parent organization,
had far less autonomy than the hospital based clinic, which was located in a modular unit
across the street from the hospital.

In the following description of the three clinics it is my goal not only to highlight
the similarities and differences listed above but also show the implicit link between the
physical layout and the institutional procedures of each of the clinics. The detailed
description of the clinics, along with the hand drawn diagram of the layout of each clinic
(taken fi'om my field notes), is intended to portray a sense of place and movement,
highlighting the interaction of patients and clinic personnel at each station in the
institutional process of the clinic.

Finally, the section titled, "The Participants," is intended to give a composite of
the subjects of this study — the women seeking care and clinic personnel. Socio-

demographic data include "client's" age, education, marital status, employment status,

45

 

 

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and health insurance, giving an overall picture of the women who were seeking prenatal
care. Socio-demographic data similarly describe clinic personnel's age, education leveL
marital status, if they have ever used Medicaid services, and number of years employed
with the clinic, and is intended to contrast some of the situational similarities and

differences between clinic personnel and client's perspectives.

The Community

Lansing, Michigan's State Capital, is located in the south central part of
Michigan's Lower Peninsula. With a population of 127,321 in 1990 (U .8. Bureau of the
Census, 1992), the city is home to Lansing Community College, the Oldsmobile Division
of General Motors, numerous insurance company headquarters, utility billing offices and
banking centers (Lansing Chamber of Commerce, 2000). Oldsmobile, founded in the
18903, continues to play an influential role in the city's development as is evidenced by
its backing of the Lansing Lugnuts Class A baseball team, which is housed in Oldsmobile
Park, and the RE. Olds Museum.

With the State Capital and General Motors located in the city of Lansing, and
Michigan State University in nearby East Lansing, the metropolitan area's largest
employers are the State of Michigan —20,000 employees, General Motors — 16,000,
and Michigan State University — 12,300 (Lansing Chamber of Commerce, 2000). Over
the past 10 years however, the most significant changes in the metropolitan area's
workforce has been a decline in manufacturing (-21%) and state government (-6%) jobs
(Lansing Chamber of Commerce, 2000). In contrast, a number of diverse industries

within the retail (+34%) and service sectors (+62%), such as warehouse/grocery retail

46

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and health care, have been steadily growing over the past decade (Lansing Chamber of
Commerce, 2000). The local community college and public school systems have
remained significant employers in the area as well.

The city of Lansing is characterized as a blue-collar town since the majority of its
residents work in factory, retail, and service industry jobs. The city proper is surrounded
by wealthier suburbs where many of the white-collar employees who work in
government, the automobile and service industries, and higher education live. Beyond
these suburbs the area becomes rural farmland with small towns and villages. While the
majority of the participants in this study lived in the city of Lansing, many also lived in
outlying towns of the greater Lansing tri-county area, which is comprised of Ingham,
Eaton, and Clinton counties. Whereas Ingham County is dominated by state government
and GM factories located in Lansing and Michigan State University in East Lansing,
Clinton and Eaton Counties are predominately agricultural areas known for grain, bean,
and livestock farming (Sommers, Lawrence M., 1977).

While the tri-county area is predominately white(Clinton 97.9%; Eaton 94.3%;
Ingham 84.1%), Ingham County is the most ethnically diverse of the three counties with
9.9% of it's population Afi'ican American and 6.0% categorized as "other" according to
the 1990 US Census. A similar trend is evident among the three counties with regard to
distribution of household income. Clinton and Eaton counties have median household
incomes of $36, 1 80 and $35,754 respectively whereas the median household income
distribution for Ingham County is $30,162 (U .8. Bureau of the Census, 1992). Although
there are no neighborhoods in the tri-county area that are populated solely by one ethnic

minority (i.e., African American or Mexican American) there are clusters of ethnic

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minority populations in concentrated areas. The greater ethnic diversity of Ingham
County and it's corresponding lower median household income distribution has, as I
discuss later in this chapter, prompted researchers to consider whether neighborhoods
such as North Lansing in Ingham County, where there is persistent and concentrated
poverty, are underclass barrios.

As early as 1910, Chicanos migrated to the greater Lansing tri-county area
(Clinton, Eaton and Ingham counties) as railroad and farm workers although the earliest
families to permanently settle in the area are documented as arriving in the 19303 (Haney,
1979). According to Haney, these early arrivals settled in north Lansing near a beet
refinery at which they worked. "Later immigrants often moved into the same general
area for social as well as economic reasons, so the north side where the sugar refinery
was located became the center of Chicano population concentration" (Haney, 1979:117).
By the 1950s Chicano migration to, and settlement in, Michigan had become a well
established pattern as the tri—county area had become home to a steadily growing
automobile industry that required increasing numbers of workers as well as an "important
truck crop region with among the highest yields of pickling cucumbers in the country
(Haney, 1979:115).

In 1990 the population in Michigan was 9,295,297 (US. Bureau of the Census,
1992). Of this, 83.5% were white, 13.8% were black, and 2% were of Hispanic origin.
According to the 1990 US. Census, the median household income for Hispanics in
Michigan was $26,939 with 23.6% of Hispanics living below the poverty line.1

From 1990 to 1996 the Hispanic population in Michigan increased by 19% (J SR1

Information Sheet #0136). As a result, Michigan has the second highest number of

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Hispanic residents in the Midwest, after Illinois, with the large majority of them residing
in the lower portion of the state's lower peninsula (Aponte and Siles, 1994). As Aponte
and Siles point out, the Hispanic population in Michigan is quite diverse — including
Latinos of Mexican origin, Puerto Ricans, Cubans, and Latinos from South and Central
America as well as Spain. Mexicans, however, account for 69% of the Hispanic
population in Michigan. While Hispanic are found working within the standard industry
categories (i.e., agriculture, construction, manufacturing etc), they are mainly
concentrated in manufacturing (20%), the service industry (20%) and retail trade (13%)
(Aponte and Siles, 1994).2

By the late 19903 3.5% of the state's Hispanic population resided in the greater
Lansing tri-county area: 1,635 in Clinton county; 2,773 in Baton county; and 16,079 in
Ingham county (J SRI Information Sheet #0136). Within Ingham county, the City of
Lansing is 8% Hispanic. Within the City of Lansing, North Lansing (discussed at the
start of this section) is home to 16.7% of the area's Hispanic population (Siles and
Rochin, 1998). As illustrated by Haney (1979) and posited by Siles and Rochin, North
Lansing is considered to be the original Hispanic settlement in Lansing, dating back to
the 19403 (1998: 2). Despite the high concentration of Hispanic residents however, the
community is home to a diverse ethnic population of Anglos, African Americans,
Hispanics, Asians and Native Americans.

The large numbers of minorities who reside in North Lansing, in particular
Hispanics, who live in poverty, has prompted researchers to consider whether North

Lansing is becoming an underclass barrio with persistent and concentrated poverty. In

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evaluating this question, Siles and Rochin (1998) compiled the following composite of
the area in contrast to tri-county area as a whole:

0 The poverty rate of Hispanics in North Lansing is almost double the rate
of the tri-county area (i.e., Latinos in North Lansing have a poverty rate of
41.4% compared to 23% in the tri--county area).

0 Hispanics in North Lansing earn considerably less income (per capita
income for Latinos in North Lansing is $5,832 compared to $8,312 for
those in the tri-county area).

0 Household composition indicates that a female heads 28.5% of Hispanic
households in North Lansing with no husband present compared to a
23.5% rate for the tri-county area.

0 Latinos 25 years and older in North Lansing have a high school graduation
rate of 44.6% compared to that of 64.3% in the tri-county area.

0 The labor force participation rate for males in North Lansing is 74%, and
54.5% for females. In contrast, 77% of males and 61% of females in the
tri-county area participate in the labor force.

As a result of these observations the authors were led to conclude that there are two
predominant Hispanic communities in the greater Lansing tri-county area — "North
Lansing, [which] reflects the 'inner city' characteristics of its 'distressed' neighborhood
and another, larger Latino community that appears to be achieving parity with the
Lansing community at large" (1998:1).

In this study, both the women seeking care and the clinics they utilized were part
of this dynamic community consisting of North Lansing and the tri-county area as a

whole.

The Clinics
The Latino Community Center Clinic

The Latino Community Center Clinic was housed in a wing of an old elementary
school that had been converted into the Community Center. Located on a quiet street in

North Lansing, the Community Center served both the immediate neighborhood and the

50

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greater Latino community in Lansing. Upon parking in the small paved lot at the north
end of the Community Center, walking by a small play ground and the community
center's garden, planted in one section of what once was the elementary school's field,
patrons entered the Community Center through heavy set of double doors. The Family
Health Clinic was located immediately to the right of this entrance, identified by only a
small plaque on the left side of the door.

The Latino Community Center offered a wide variety of services ranging from
after-school childcare to a food subsidy program for migrant agricultural farm workers to
Alcohol Anonymous programs. In keeping with the Community Center's mission, the
Family Health Clinic ran a general practice. Specialized clinics, such as pediatrics and
obstetrics/gynecology, were run one afternoon or morning each week. During these
clinics, the health center staff was augmented by pediatric and obstetric/ gyneco logy
specialists who were either in private practice or medical school residents. In the
summer, the health center ran a mobile migrant health clinic which visited local migrant
farm worker camps one evening each week.

The health center, located on the first floor of the Community Center, was
comprised of a waiting room, reception area, and an exam area. Patients entered the
clinic through a door off of a main corridor in the Community Center that led to the
waiting room, which was a comfortable-sized room filled with vinyl, office style couches
and plastic chairs. A television, mounted on a high shelf, was usually turned on to a talk
show or soap opera. In one comer a small children's table had been set up where a

variety of donated toys were available for kids to play with.

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Latino Community Center Clinic

The reception window was to one side of the waiting room. Behind the window
three receptionists, their computers, and the majority of the patient files were crammed
into what had once been a utility closet. Patients signed in at the window upon arrival, at
which point the receptionist would pull the patient's file and walk it back to the staff in
the exam area. Aside from facilitating patient check-in, the receptionists scheduled
appointments, arranged for treatment required at other facilities, such as private offices or
a hospital, and handled all of the patient accounts and billing, as well as other routine
office business.

The three receptionists were all Mexican American women who spoke Spanish
fluently. While almost all of the patients who attended the health clinic spoke English,
many preferred to schedule appointments and discuss payment options in Spanish. Two

of the receptionists were women in their thirties, married with at least one child each.

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The third, who had recently been hired, was in her early twenties, single, and had two
children.

The exam area was entered through a door ofi‘ of the waiting room. The nurses'
station, essentially a counter top with cabinets on one side of a small central hallway, was
the focal point of the exam area. Three small exam rooms were on the right side of the
hallway with two separate closet sized spaces that served as offices for nurses and
physicians respectively. In these small offices the nurses piled their paperwork, reviewed
charts, and did patient follow up. Physicians similarly used their space to review charts
and dictate chart notes.

With only three full-time nurses and one part-time nurse, the clinic was
chronically understaffed. The head nurse, the Program Director, a Mexican American
woman in her fifties, was a veteran emergency and obstetrics/gynecology nurse who had
worked at a local hospital before joining the Latino Community Center Clinic 13 years
ago. She herself came from a family that migrated from Texas to Michigan as
agricultural farm workers and spoke Spanish fluently. Her two colleagues had similar
nursing background, one having worked in a hospital based obstetric/gynecology unit and
in a private practice, and the other as an emergency room nurse in a military hospital.
The second nurse spoke Spanish fluently as her husband's family, who were Mexican,
spoke primarily Spanish. While the third nurse, who had recently been hired, did not
Speak Spanish she was trying to learn the language through her interactions with both her
clients and her two co-workers.

The part-time nurse, who split her time with a private practice, had been gone on

sick leave for almost the entire seven months that I collected data in the clinic. She

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obstetrics/gynecology clinic.

When I began collecting data in the health clinic the Medical Director of the
Family Health Clinic had recently resigned. In the interim the Head Nurse was filling in
while the Community Center Board of Directors searched for a replacement. While a
new Medical Director was hired in the last month or so that I was at the clinic, 1 came to
know the daily routine of the obstetric/gynecology clinic as it was run under the
leadership of the Head Nurse. The Obstetric/Gynecology Clinic was open on Thursday
mornings from 8 am. to noon every week. An obstetrician/gynecologist, who was in
private practice, arrived at 8 am. and saw patients on a twenty minute rotation non-stop .
throughout the morning. If a woman needed follow-up care that the clinic was unable to
provide the physician would refer her either to his own practice or to a local hospital,
depending on the nature of the care needed. The physician, an Asian man in his fifties
who emigrated fiom Korea with this wife 25 years ago, did not speak a word of Spanish.
He relied upon the nurses to translate for him when necessary and often joked that he

didn’t think he would be able to learn a third language.

The Hospital Clinic

Unlike the Latino Community Center Clinic, the Hospital Clinic 301er practiced
obstetrics and gynecology. Monday through Friday from 8 am. to 5 put. patients were
seen by one of the hospital's 12 residents who were completing a rotation in obstetrics
and gynecology. The clinic was created by the hospital to serve two primary purposes: 1)

to offer care to low-income women; and 2) to give residents experience in working with

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low-income women. Separate from the Maternity unit, which was located in the hospital,
the Hospital Clinic was set up to offer services similar to those offered in private
obstetric/gyneco logy practices.

The Hospital Clinic was located in a small, brown modular unit located in a
parking lot across the street fi‘om the hospital. The parking lot was originally intended to
serve as "overflow" parking for both the hospital and adjacent medical offices. Always
jammed with cars, the lot was further congested as a result of a massive construction
project (an addition to the hospital) that abutted the access road to the lot. The modular
unit had two entrances fiom the parking lot —one on each end. The entrance to the
Hospital Clinic was on the right. The door on the left was for a small set of offices that
were vacant. After finding a spot to park and walking through the congested parking lot,
patients walked up a weathered set of wooden stairs or a handicapper access ramp to
enter the clinic through a small, windowless steel door. Upon entering the building one
stepped into a very small waiting room that was lined with plastic chairs around its
perimeter. Interspersed among the chairs were a couple of tables strewn with parenting
and family magazines. A television, mounted on a wall unit, was usually tuned to a talk
show or soap opera. Patients were asked to sign in at the reception window upon their
arrival and take a seat until called by the nurse.

The receptionists' area, which was accessible to the waiting room via the
reception window, was a cramped space that housed three receptionists, their computers,
and all of the patient records, which were filed in tight rows of tall steel case shelving.
Behind the receptionists and off to one side of the files was a small desk used by the

nurses to make follow-up calls and take incoming phone calls from patients with

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Hospital Clinic

questions. The receptionists were responsible for scheduling appointments, checking in
patients, and handling patient accounts. One receptionist was single and in her mid-
twenties. The other two were both married and in their late thirties, early forties. All
three of the women were white and did not speak Spanish.

The "clinic" area was entered through a door off of the waiting room. In the
center of this area were two nurses' stations that were large island countertops with
cabinets. While residents used this space to confer with the nurses and make notes in
patient charts, this was primarily the nurses' space. Three nurses worked at the clinic —
one at each station and the third acting as the "phone nurse" in the receptionists' area.
Based upon a schedule, the nurses would rotate between the three positions. All three of

the nurses were over 40, married, and white. None of them spoke Spanish.

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To the right of the nurses' stations, along the perimeter, was the Clinic Directors'
ofice, a conference room, the Resident Program Director's oflice, the physician on call's
oflice, and a resident's lounge. The Director of the Clinic was a nurse who coordinated
the clinic schedule and Iiased with the Residency Program Director's office as well as the
hospital as a whole. As a result, she was out of the clinic more often than not. While the
conference room was open to all for use, it was routinely used by the nurses to conduct
intake interviews with new prenatal patients. The door to the Resident Program
Director's office was closed most days and the staff in that office seemed to have little
interaction with the clinic staff or the daily routine of the clinic.

To the left of the nurses' station was the social worker's office and six exam
rooms. The social worker was employed by the hospital full-time; however, she worked
in the Hospital Clinic a maximum of 20 hours per week. Although the rest of her hours
were spent seeing clients in other areas of the hospital, the Hospital Clinic staff could
reach her if needed. The six exam rooms were comfortably sized, simple rooms adorned
with various posters depicting fetal development and the male and female reproductive
systems. Each exam room had a supply cupboard, an exam table, and stool for the
practitioner to sit on

The 12 residents rotated through the clinic such that usually two residents were in
the clinic each day. Each resident's schedule was kept in a blue three-ring binder in the
receptionists' area. The receptionists scheduled patients with each resident accordingly.
Women were asked to check in at the reception window, wait in the waiting room, and

then, were called by a nurse to an exam room where their blood pressure and weight were

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taken. The resident would then conduct the rest of the prenatal exam. Although a

resident saw patient, there was always a physician on call to consult.

The Public Health Clinic

The Public Health Clinic, housed within a large Department of Public Health
building, was centrally located on the south side of Lansing. The Public Health building,
which had four separate main entrances — one for each of its agencies, was surrounded
by a massive parking lot filled with a sea of cars. City buses stopped at two bus stops
centrally located between the four main entrances as well. Upon entering main entrance
#3, patients found themselves in a wide, spacious lobby lit with natural light from the
large windows that made up the majority of the ham of the building. The Clinic, located
on the second floor, was one of many clinics/facilities that offered services ranging from
a variety of health care clinics to community health programs. Compared to the Latino
Community Center Clinic and the Hospital Clinic, the Public Health Clinic was large and
spacious. The clinic was entered through a wide set of double doors off of a second floor
lobby that lead to the primary waiting room. Bright and spacious as a result of the floor
to ceiling windows on one side of the room, the waiting room offered a variety of
cushioned wooden chairs for women to sit on that were interspersed among floor plants,
tables full of reading materials, and children's toys. In a corner, housed in a television
cabinet, was a TV and VCR that played a variety of educational videos at the top of each

hour.

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Public Health Clinic

The reception area, accessible to the waiting room via the "window," as it was
called, was a long open room in which a number of activities took place. The "window"
was fi'onted by two stations at which patients were asked to sign in upon arriving. Two
other workstations were to the left and right of the window. In the center of the room
was a large counter where patient charts were reviewed and prepared for office visits. At
the back of the room was the Front Office Coordinator's desk. This area also housed all
of the patient charts as well as the office photocopier. Four women worked in this area,
the Front Office Coordinator and three Women's Health Clerks, who were responsible for
checking in patients, scheduling appointments, facilitating payment options, providing

women with Medicaid forms, and file management. Two of the women were white, one

59

 

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African American, and the fourth, Mexican American. They ranged in age fiom twenty-
something to their late fifties. Only the Mexican American women spoke Spanish.

The offices of the Lead Social Worker, Clinic Coordinator, and the Charge Nurse
also adjoined the primary waiting room area. As their titles imply, these women were
each responsible for running different aspects of the clinic, with the Clinic Coordirmtor
overseeing all aspects of the clinic in its entirety. All three were white, over 40, and did
not speak Spanish

The final area that adjoined that primary waiting room was the Laboratory.
Commonly referred to as "the lab, " this was the area where women gave urine samples,
had blood drawn, and were weighed at each of their prenatal visits. The lab was a fairly
good sized room lined with counters and cabinets that held various supplies and had it's
own private bathroom. The lab itself was manned by one woman who was in her mid-
thirties. She was white and did not speak Spanish

Through the corridor leading off of the primary waiting room was a smaller
secondary waiting room. Lined with cushioned wooden chairs along the perimeter of the
room, this was where women waited between their interview with a nurse and their
physical exam. Reading material about pregnancy, childbirth, and parenting was
available as well as a video on childbirth, played hourly, on the TV mounted on the wall
in the comer of the room. Often an outreach educator would hold small group
discussions with a number of women and their partners about childbirth while they
waited in this area.

To the right of the secondary waiting room was a hallway along which were the

Clinic Nurses' offices. These nurses met with women at each of their prenatal exams to

60

discuss the progression of their pregnancies and questions or concerns women might have
about their physical health, emotional support, and economic issues as well. The six
Clinic Nurses, including the Charge Nurse, ranged in age from their mid-twenties to their
late fifties. Four were white and one was Korean. The Korean Clinic Nurse spoke
Korean fluently, and while the rest of the Clinic Nurses did not speak a second language,
many of them were trying to learn Spanish or kept a Spanish phrase book handy.

At the end of the corridor was the education/coffee room. In reality this room
didn't have an official title, it was simply a small back room that overflowed with
educational materials, on topics such as sexually transmitted diseases to a variety of
pregnancy issues, that were stored in floor to ceiling shelves. Many of the materials were
in duplicate as the leaflets were available in both English and Spanish. The staff in the
clinic had saved their recyclables and pooled their money to purchase a small refiigerator
and a coffee maker in an effort to have a break and coffee room of sorts. While there was
barely enough room to stand in the room let alone sit, staff would pop in and out of the
room to refill the coffee mugs and talk briefly in between seeing patients.

The hallway to the left of the secondary waiting room led to the exam rooms, the
Clinic Assistants' station, the physicians' conference room, and the Nurse Practitioners'
office. The six exam rooms along the left-hand side of the hall were for the most part
off-limits to all but the Clinic Assistants, the Nurse Practitioners and the physicians. As a
result, I was only able to get a quick glimpse into an exam room as I walked down the
halL They appeared to be average sized rooms, without windows, that were firmished in
the usual style — exam table, stool, cabinets, chair, and educational pictures on the wall.

The Clinic Assistants' Station, on the right of the hallway, was a large room lined with

61

red countertops and white cabinets in which medical supplies were stored. Clinic
Assistants reviewed charts and met with Nurse Practitioners and Physicians in this area to
discuss patient charts. At the end of the hallway was the Nurse Practitioners' office and
the Physicians' conference room. The clinic employed two full-time and two part-time
Nurse Practitioners who saw patients for both obstetrics and gynecology. Patients were
also seen by university faculty physicians and residents from a nearby hospital-based
family practice residency program. While the nurse practitioners shared an office at the
back of the clinic the faculty physicians and residents used the conference room as their
office and break room. Like the physicians and residents, the nurse practitioners'
activities were for the most part confined to the left corridor of the clinic where the exam
rooms, Clinic Assistants' Station, Nurse Practitioners' office and physicians' conference
room were located. As a result, they not only had very little interaction with the larger
clinic stam but they also seemed to me to be faceless names that worked in a clinic
within the clinic.

At each appointment a patient's progression through the clinic followed a precise
formula. The patient checked in at the reception window upon arrival and then waited in
the primary waiting room. When called, the laboratory assistant would escort the patient
into the laboratory where her weight was measured and a urine sample taken. The
laboratory assistant would then escort the patient back to the primary waiting room and
place the patient's chart in a window that looked into the secondary waiting room. One of
the clinic nurses would pick up the patient's chart from the window and then take the
patient from the primary waiting room back to her office for a prenatal interview. After

the interview the clinic nurse would escort the patient to the secondary waiting room and

62

place the patient's chart in a standing file in the clinic assistants' station. From the
secondary waiting room a clinic assistant would escort the patient to an exam room where
she would be examined by either a nurse practitioner, a faculty physician or a resident.
After her exam the patient would meet with either a social worker or a nutritionist, if
needed. On her way out, the patient would stop at the reception desk to schedule her next
appointment, and the patient's chart would be returned to the fiont office by whoever had

itlast.

The Participants
The Clients

The 27 Mexican American women interviewed in this study were patients at one
of the three clinics described above. (See Appendix C, Part A for more detailed
demographic data on women who participated in this study.) Women were between the
ages of 18 and 36, the average age being 23. Their education levels ranged fiom
completion of the sixth grade to a four-year college degree. Thirteen of the women were
born and raised in Lansing, three were born in small communities surrounding the greater
Lansing area, four were born in southern states such as Texas and Florida, and the
remaining seven were born in Mexico. Women who were born in the southern United
States and Mexico either settled out of the agricultural migrant stream with their families
when they were quite young or came when they were teenagers or adults to live with
boyfi'iends, husbands or extended family members. Fifteen of the women were single,

1 l were married, and one was divorced. Women had anywhere fiom zero to four

63

children, the average being 1.2. At the time of the interviews 11 women were employed
outside of their homes and 16 were not.

As per the State of Michigan Family Independence Agency's 1997-1998
guidelines for Medicaid services, all of the women I interviewed were considered to be
low-income clients. For example, a family of three with a monthly income of $1,623 or
less was considered low-income and thus qualified for Medicaid coverage. Nineteen of
the women I interviewed were on Medicaid, four were in the process of applying for
Medicaid, one was covered by her husband's private health insurance policy, and three
had no insurance of any kind. Two-thirds of the women used other services, such as

Women, Infants, and Children Special Supplemental Feeding Program (W1C).

The Clinic Personnel

Personnel from each of the three clinics were interviewed for this study as well.
In all, five Reception Clerks, eight Clinic Nurses, one Nurse Practitioner, and one
Physician were interviewed. Clinic personnel were between the age of 21 and 59, the
average being 43. (See Appendix D, Part I for more detailed demographic data on clinic
personnel who participated in this study). Their education levels ranged from a General
Education Diploma (GED) to various Masters' degrees to a MD. Four of the clinic
personnel were born in Lansing, six were born in other areas of Michigan, three were
born in other US states, and two were born in Asian countries. When asked to identify
their ethnicity, clinic personnel answers ranged from White American, Irish-Polish, and

Caucasian, to Hispanic, Mexican American, Korean American, and Asian. Based on the

US Census criteria for race/ethnicity, 10 were "white," three were Hispanic, and 2 were
Asian.

Of the clinic personnel interviewed, there were 14 women and one man. Two
were single, six were married, six were divorced, and one was widowed. Clinic
personnel had anywhere from one to four children, the average being two. At the time of
the interviews, clinic personnel had an average of 15.4 years of overall experience in the
health care profession and had been employed with their respective organizations for an
average of 7.3 years.

With the exception of the physician who volunteered his time to the Latino
Community Center Clinic, all of the Clinic personnel in this study used private health
insurance policies provided to them by their respective employers. Five clinic personnel,
however, indicated that they had used Medicaid Services prior to beginning their careers
in the health care profession. While none of these clinic personnel cited health insurance
coverage as a significant motivation in their career choice they did admit that coverage
was a very attractive benefit. Of the five clinic personnel who had used Medicaid, two

were employed at the Public Health Clinic and three were employed at the Latino

Community Center Clinic.

Entering the Field

The relationship between the clinics and their parent organizations greatly
influenced my own access as a researcher to each of the clinics. My entrance into the
Latino community center clinic was greatly eased by the fact that I had ridden with the

mobile migrant health clinic during the preceding summer. Furthermore, I was

65

introduced to both the director of the community center and the head nurse of the health
clinic through a personal contact. The time I could spend in the clinic collecting data was
limited, however, as prenatal patients were seen only one morning per week. The
attending physician preferred that I review his list of appointments, generated by the
"front desk," so as to select women who were potential subjects. Due to the limited
schedule and equally limited space, the clinic was often overflowing with patients. As a
result, interviews with women at this clinic were, for the most part, conducted in a
relatively quiet and private corner of the waiting room.

The administrative structure of the Public Health Department as a whole, and, in
turn, the regirnented format of the Public Health Clinic, stipulated that I start at the top of
the organization in gaining access to the Public Health Clinic. Upon meeting with
director of the clinic, she submitted my curriculum vitae, research proposal, and cover
letter outlining my study to the Director of the County Health Department. Once this
Director gave his approval, I then presented my proposed research to the staff of the

clinic at their weekly staff meeting. This entire process took about three months. The
physical layout of the clinic itself reflects the administrative hierarchy of the department
with regard to both the location of clinic personnel' stations and the order in which
patients move through the routinized process of care. Receptionists were stationed at the
fi'ont of the clinic, nurses, nutritionists, and social workers were housed in offices in the
center of the clinic, and the physicians' lounge was located at the back of the clinic.
Patients checked in with the receptionist, were assessed by Clinic Nurses, and then seen
by a physician in an exam room near the physicians' lounge. In keeping with this routine,

the head nurse decided it would be best to insert my interview into this equation as

66

women often had "downtime" between their assessment with the nurse and their exam
with the physician. Since all of the omces were occupied and exam rooms were often in
use, I was given the coffee/education room by the back door of the clinic to conduct my
interviews. Neither the Director of the clinic nor the head nurse felt it would be
appropriate for me to conduct my interviews in the waiting room as they thought it might
inconvenience other patients.

As per clinic protocol, the Charge Nurse would review patient charts each
Monday morning. After much discussion about how potential participants for my study
would be identified, we agreed that she would insert a copy of the consent form for my
study into the files of women whom she believed to be Hispanic. She identified women
as potential participants using one of the following criteria: 1) their first or last name; 2)
if they had checked "Hispanic" on their intake sheet; or 3) any first hand knowledge of
the woman. The presence of the consent form for my study, copied onto bright orange
paper so it would stand out from other documents in the patient's chart, thus acted as a
flag to Clinic Nurses when they assessed a patient. The Clinic Nurse would explain my

study to the patient and then ask her if she was willing to meet with me. If the woman
agreed, the Clinic Nurse would escort her to the coffee/education room where I was
waiting.

I had anticipated, wrongly so, that the most difficult clinic for me to gain access to
would be the Hospital Clinic. Imagining that the atmosphere at this clinic would be
highly suspicious of a student conducting research and dreading the lengthy formalities of
the hospital's internal review board (IRB) process, I envisioned a process similar to my

exPerience at the Public Health Clinic. I met with the director of the clinic and explained

67

my proposed research, emphasizing that my goal was not to disrupt the clinic's daily
routine in any way. The director seemed quite at ease with my proposed activities. She
confirmed that I had IRB approval from Michigan State University, said that she would
make sure that I did not need approval from the hospital IRB, and then asked me if I
wanted to start that very day. We agreed that I would wait until she had confirmed that I
did not need approval fiom the hospital [RB and that, in the meantime, she would explain
my study to the nurses in the clinic. Two weeks later, I walked into the clinic, introduced
myself to the staff again, and I began collecting data. In retrospect, I realize that my
entrance into this clinic was greatly eased by the fact that the clinic was part of a teaching
hospital. As a result, the director and the staff were quite used to having students, both as
interns and researchers, in the clinic.

The head nurse suggested that I review the physicians' appointment schedules on
a weekly basis to screen for patients who would qualify as potential participants in my
study. As the clinic was always behind schedule, she thought it would be best that 1
interview women before their exam, as it would distract them during their wait to see a
physician. Located in a small modular unit, the clinic had an extremely small waiting
room, a packed receptionist area, a central nurse/physician station, and a couple of exam
rooms. It was agreed, as a result, that the best place for me to conduct interviews was an
empty exam room. Consequently, I greeted women in the waiting room, explained my
study, and then, if they agreed, interviewed them in an empty exam room. Alter the
interview, I would escort them back to the waiting room.

Although my goal was carry out research at the clinics in sequence, due to

scheduling I was conducting interviews at all three of the clinics concru'rently for a

68

couple of weeks. In this time I became aware of the striking ways in which both the
physical structure and administrative structure of each organization in turn influenced the
dynamics of my interviews. While all of the interviews were informal, due to both the
open-ended format of the questions and the personal/intimate nature of pregnancy and
childbirth, it became apparent that interviews conducted at the Public Health Clinic and
the Hospital Clinic began with a much more formal air. I had to work harder at
establishing a personal rapport with women than I did at the Latino community based
clinic. In both the Public Health Clinic and the hospital center clinic participants
perceived me as being part of the health care organization. This was mostly due to the
fact that at the Public Health Clinic prospective participants were escorted to me by
nurses and at the hospital based clinic I came through the closed door separating the
waiting room and the "clinic area" to ask women to participate in my study. In
comparison, at the Latino Community Center Clinic, I sat in the waiting room with
women both during the interview and in between interviews. Although I would often
step behind the door to the exam rooms to check in with the nurses or talk with the staff
at the front desk, for the most part I was perceived as someone in between these two
realms. As a result, I made a special effort in interviews with women at the Public Health
Clinic and the Hospital Clinic to explain that I was not affiliated with the clinic in any
way. Furthermore, I emphasized that our discussion would have no impact on the care

they received as a patient in the clinic.

69

Endnotes

 

' Comparatively, in 1990 the median household income for Whites was $32,483 and $18,851 for Blacks
with 9.5% of Whites and 33.7% of Blacks living below the poverty line respectively (US. Bureau of the
Census, 1992).

2 Aponte and Siles (1994) note that while agricultural workers are shown to account for only 3% of
Hispanic workers this number would most likely rise if migrant workers were counted in the census.
Migrant workers are often not included in the census however, as they are not in Michigan at the time of

the census.

70

Chapter 4: Women's Social Resource Management and Strategies

Low-income Mexican American women manage access to prenatal care by
drawing upon a variety of social resources that are economic, political, as well as
medical. In doing so they create strategies that are based upon the broad scope of social
resources that are available to them. The findings in this chapter identify and discuss the
social resources that women in this study most commonly relied upon in gaining access
to prenatal care. Women's responses illustrate that the process of gaining access to
prenatal care can be roughly broken into three categories: a) finding out about prenatal
care; b) finding out about and choosing a clinic that offers prenatal care; and c) figuring
out how they will pay for their prenatal care. As such, the social resources that women
utilized are examined within the context of these firndamental questions. (See Appendix
C, Part II for the quantitative breakdown of women responses.)

Whereas the first half of this chapter discusses the most common social resources
women draw upon to gain access to prenatal care the latter half of this chapter will
illustrate the strategies women develop to facilitate this process. The decisions that
women make in drawing upon the various social resources available to them are not
isolated or independent events but rather a series of actions that are linked together with
the aim of achieving a specific goal. In drawing upon resources available to them
through social networks women create alliances that form the basis of the strategies they
develop to gain access to prenatal care. The goal of the latter halfof the chapter is thus to
exemplify that women are actively and consciously selecting fiom and using the social

resources available to them to gain access to prenatal care.

71

Women's Social Resources
Why Women Think They Need Prenatal Care

Of the 27 women interviewed in this study, 25 had begun receiving prenatal care
in the first trimester of their pregnancy. Two women had not started receiving prenatal
care until they were well into their 3rd trimester. In both cases this was due in part to
travel. Margarita's arrival in Lansing illustrates how travelling fi'om Mexico made it
difficult for her to obtain prenatal care. 30 years old, Margarita had been working in a
maquiladora in northern Mexico. While in Mexico she met her boyfriend, an American
construction worker from Michigan. When Margarita realized that she was three months
pregnant she and her boyfriend decided to get married. Once married Margarita and her
new husband moved to South Carolina where her husband completed a two-month
project for his construction company. When Margarita and her husband finally arrived in
Lansing, she was 31 weeks pregnant. Margarita explained that as her husband's
construction company did not offer any health benefits, and she was unable to complete
the enrollment process for Medicaid since they were in South Carolina for such a short
period of time, she had not had any prenatal care thus far during her pregnancy.
Furthermore, the short duration of their stay in South Carolina combined with isolated
living conditions limited Margarita's chances to develop a social network from which she
could learn about clinics that offered free prenatal care. She was waiting for her first
prenatal exam at the Latino Community Center Clinic when I interviewed her.

Margarita's situation raises two key points that are central in considering women's
access to biomedical health care during pregnancy and birth: 1) why women believe that

they need prenatal care; and 2) how they find out about prenatal care. With regard to the

72

first question, why women thought they needed prenatal care, women's responses in this
study can be roughly broken into seven categories:
Figure 4.1

Why Women Value Prenatal Care
N, number of responses = 36

 

 

8%
Find out
Problems
19%
Not Sure
6%
Good for
Mothers Health 39*
Protect the Baby
8%
”Needed when
pregnant"
14%
Get Vitamins
6%
hooked
a Doctor

The most corrunon reason that women cited for obtaining prenatal care was
grounded in a preventative care interest for their baby.I Women often responded that
they felt prenatal care was important "To make sure that nothing happens to the baby," or
that it was good to receive prenatal care so that they could "Find out problems with the
baby." A typical response to my interview question was:

Something could be wrong and they could
find out and correct it before the baby is
born. [Jennifer, age 23]

Embedded within these statements was the underlying premise that biomedical prenatal

care would prevent "problems" from happening in the first place.

73

Many women who cited preventive care as the most important reason for prenatal
care also said that they valued prenatal care for the vitamins that were prescribed by the
physicians. When asked why they felt it was important to take a prenatal vitamin many
women responded: "I need vitamins. I want to have a healthy baby" [Jennifer, age 23].
Such responses supported a curative perception of prenatal vitamins in which the vitamin
was thought to not only prevent abnormalities but cure them as well. A few women,
however, viewed prenatal vitamins as a supplement — a pill that would boost their
nutritional status.

I went to a free clinic in California. I knew
my eating pattern wasn't the greatest and

that prenatal vitamins would help me eat
right. The vitamins help my nutrition.

[Judy, age 18]

In contrast to the latter group of women who cited the preventative attributes of
prenatal care for the baby only two women perceived prenatal care as being beneficial to
their own health. While both of these women first explained the importance of prenatal
care with regard to the health of the baby they firrther articulated the benefits of prenatal
care in terms of the health of the mother.

It is good for the development of the baby.
It's good for myself I need the nutritional
guidelines. [Anna age 27]

So you know your baby is air. You hear
about kids having babies in bathrooms who
didn't get care. It could have died in your

body and could have messed your body up.
[Patricia age 22]

74

At the time of our interview Anna, a certified Nurse's Aid who was 6 months pregnant,
was enrolled in Nursing School. Her perception of prenatal care as being beneficial for
both the baby and the mother was greatly influenced by the biomedical model she was
learning in schooL In contrast, Patricia's argument for the benefits of prenatal care
burgeoned out of discussions about teen pregnancy with family, fi'iends, and the media.
She explained that as a cashier at a local convenience store, she fi'equently read the
magazines on the store racks. The articles she read prompted her to talk about teen
pregnancy with her family and friends; thus she heard similar "real life" stories that
confirmed what she had read in magazines. The "real life" stories and magazine articles
in turn led Patricia to value prenatal care for both her own and the baby's health and,
consequently, reinforced her belief in the biomedical model of prenatal care.

Some women in this study stated that prenatal care was important, yet they were
unable to articulate why they believed this to be true. After some probing, this group of
women gave responses such as "It is important to be checked by a doctor" and "You need
it when you are pregnant." The women viewed prenatal care not as an option but rather a
biomedical imperative that they embodied as a "norm" of pregnancy.

Prenatal care is normal — I don 't know.

The clinic tells you you're pregnant. [ Maria,
age 21]

When you get pregnant you go to the doctor.
[Jennifer, age 23]

Whereas women falling into the latter category were ultimately able to reason that
prenatal care was an expected routine of pregnancy, women (19%) were unable to

articulate any reason for obtaining prenatal care. Although women in this situation were

75

ofien able to give a general overview of what their prenatal visits involved —— meeting
with a nurse, being weighed, and being examined by a physician — they were not able to
explain the ramifications of these activities. Women ofien responded with a simple, "I'm
not sure," or "I don't know." Such responses seemed to support a notion of prenatal care
as a normative expectation of pregnancy as women complied with the routine despite the
fact that they didn't understand its purpose; much less were they able to articulate a
reason for their compliance. This in turn brings to light the centrality of the second
question raised at the start of this discussion: How do women find out about prenatal
care? If women are unsure of the purpose of prenatal care yet they seek it, how then do
they find out about it in the first place?

Figure 4.2

How Women Found Out About Prenatal Care
N, number of responses = 33

Number of Reopomeo
l

 

 

g: Sibling ‘Family Friend School am Remember
I

76

As the previous graph (Figure 4.2) shows, women indicated that they found out
about prenatal care in a variety of ways. The most common sources of information about
prenatal care were their mothers, other family members (including both immediate and
extended family), friends, and school. Each of these resources however, translated the
need for or expectation of prenatal care in a variety of ways. For example, women's
responses reflected passive statements such as "I was raised to have it" to more

interactive scenarios:

Mom had four kids. When she first found
out I was pregnant she said, "we have to get
you some prenatal care. " [ Rosie, age 19]

My mother taught me. You grow up
knowing things. She saw that we had check
ups. When you get pregnant you go to the
doctor. [Jennifer, age 23]

My mom made me go because I have such
low iron. [Emma, age 28]

Women who found out about prenatal care fiom both immediate and extended
family members as well as from friends often related more involved explanations that
wove together broad familial, social, and work-related networks. For example, Veronica,
age 25 and pregnant for the first time, explained that she learned "the process" from her
sister who had two children and was also pregnant.

When I first found out I was pregnant I j ust
had to sit back and take it all in but

Stephanie was like now we have to this and
this and that. She knew what to do because

she has two kids. It's all new to me and I
had to sit back and think about it.

77

Veronica was further "educated about the process" by her neighbors whom she described
as older friends who had children. Since she owned her own car, Veronica often helped
her fiiends out with childcare, rides to prenatal appointments, and food shopping. She
thus learned about prenatal care from an immediate family member, her sister, and

friends with whom she had developed a social and economic relationship as well.

How Women Find Out About And Choose A Clinic

Examining why women believed prenatal care was important and how they found
out about prenatal care in turn raises the question of how women found out about, and
ultimately chose, a clinic for obstetrical care. Women interviewed in this study were
patients at one of three "health clinics" —each clinic representing a different biomedical
organization. When I asked women shy they had come to a particular clinic, their
responses revealed that they used a variety of resources to inform their decisions as well
as strategies influenced by their perceptions of the organizations themselves.

Regardless of the organization, women most commonly indicated that they found
out about and chose a clinic based on the suggestions of family and friends (Figure 4.3).
For some women, finding and choosing a clinic was as straightforward as having a friend
or a sister who referred them to the clinic they had used when they were pregnant. Other
women similarly chose to use the clinic at which a sister or friend worked. For example,
Tina explained that she never thought to go to any other clinic than the one at the Latino
Community Center where her sister worked as a receptionist. Although friends had told
her about other clinics in the area her "inside connection" at the Latino Community

Center Clinic clinched the decision.

78

Figure 4.3
Basis of Women's Clinic Choice
N, number of responses = 35

6%

 

 

 

*"Hospital Information" refers to information about prenatal clinical services gathered by
women from both hospital personnel and hospital brochures about prenatal care.

Many women, however, were not as fortunate as Tina was with her inside
connection. Furthermore, the majority of women who found out about and chose a clinic
based upon the insights of family and friends gave responses that reflected far more
complicated pathways. For them, finding out about and choosing a clinic involved
negotiating a complex network of familial, social, and work-related resources. For
example, Veronica's path to finding the Hospital Clinic began with a friend of her sister.

A friend of my sister had to get help from the
State. My sister called her to find out what
to do. She referred us to Planned

Parenthood. I went there and got a
pregnancy test and they told me about [the

79

Hospital Clinic]. After that we were like,
"Oh, what now?" [Veronica, age 25]

Rosalinda, age 23, married, and pregnant with her second child illustrates yet an
even more complex path to choosing a clinic for it transcends two countries, a social
network born out of her husband’s work relations, and two biomedical clinics. Born and
raised in Mexico, Rosalinda met her husband when his company was building a golf
course near the city in which she lived in Mexico. They married and soon found out that
Rosalinda was pregnant. Rosalinda had one child already, so she went back to the same
physician she had seen during her first pregnancy. Her husband's company, however,
had finished building the golf course so Rosalinda and her daughter moved to Michigan
with her husband. Since she did not know how to drive and her husband worked during
the day, Rosalinda's husband's employer's wife offered to drive Rosalinda to the County
Health Department where she was given a list of clinics to choose fiorn. Although
Rosalinda lived almost 40 minutes outside of Lansing, she chose the Latino Community
Center Clinic because it had the first available opening for prenatal care. Rosalinda's
decision thus followed a complex path that was fimdamentally shaped by a broad
Spectrum of familial, social, and work related networks that spanned two countries and

two biomedical health organizations.

While family and fi'iends played significant roles in how women found out about
clinics, other factors such as location, appointment availability, and the reputation of a
clinic were also central to women's choice of a clinic. For example, Sara, age 25, married
with three children, lived in the neighborhood where the Latino Community Center

Clinic was located. As Sara did not have a car, the close proximity of the clinic thus was

80

the mitigating factor in her choice. Although Sara would have preferred to see a
physician at the Public Health Clinic, as she had for her first two pregnancies, she
realized that it would be unrealistic for her to ride her bike to the southern part of town
where the Public Health Clinic was located. She did not discuss using a bus. Thus she
chose the Latino Community Center Clinic, to which she could easily walk.

Although location was an issue in Rosalinda's case, since she depended upon her
husband's employer's wife to make the 40-minute drive to the Latino Community Center
Clinic, it was not the deciding factor for Rosalinda. Since all of her clinic choices were
some distance away fiom her home, appointment availability outweighed location. When
Rosalinda and her husband arrived in Michigan, she was 18 weeks pregnant.
Consequently, she felt that waiting two to three weeks for a prenatal appointment was not
an option. Thus, despite the drive, Rosalinda chose the Latino Community Center Clinic
because they could schedule her first prenatal appointment the very same week that she
called to inquire about the clinic.

The reputation of a clinic also factored into women's decisions. In the most
fundamental sense, fi'iends and family who recommended it established a clinic's
reputation as "good." Women also equated the reputation of a clinic with the hospital at
which a clinic's physicians had admitting rights. This was especially true in the case of
the Hospital Clinic. Finally, some women based their decision upon the reputation of the
clinic, and its larger parent organization, within their communities. For example,
Theresa, age 21, married with one child, lived in the same neighborhood as the Latino
Community Center Clinic but she chose the Hospital Clinic because it seemed more

"professional. " She perceived the Latino Community Center Clinic, which also handed

81

out free food and clothing, as being for "poor" people. In contrast, Theresa interpreted
the primarily clinical services provided by the Hospital Clinic as more professional —
meaning that it had more modern equipment and "better" staff. Thus for Theresa,
professional reputation, not location or appointment availability, was the determining

factor in her clinic choice.

Finding Out about and Enrolling In Medicaid

Of the 27 women interviewed in this study, one woman had private health
insurance, four were in the process of applying for Medicaid, 19 were enrolled in
Medicaid, and three had no insurance of any kind. At first glance, these numbers seem to
indicate that low-income women, specifically Mexican American women, do not have
health insurance because they are unemployed and thus must use Medicaid. When
considered in the context of women's social and economic everyday experiences
however, the numbers actually tell a very different and complex story.

As Figure 4.4 illustrates, only 10% of women considered themselves unemployed
whereas a majority of the women who participated in this study were employed outside
of the home either at the time of the interview or before they became pregnant. The jobs
women worked in ranged from maintenance to a security guard to a nursery school
assistant; however, nearly half of the women worked in the food service industry as
cashiers and waitresses. Despite the fact that the women were all employed, none had
private health insurance. For the most part women in this study worked in jobs that did
not include health insurance benefits, as either full benefit packages or pro-rated group

plans in which a premium is deducted from the employee's paycheck. Although a few

82

women did have the latter option, they found that they were not able to make ends meet

after the premium had been deducted from their paycheck.

Figure 4.4
Women's Work Activities in Pregnancy
N, number of responses = 23

Childcare!- .

 

 

 

 

The five contiguous categories in the pie chart represent responses women gave for not
being employed outside of the home during pregnancy. Women in these categories, with
the exception of "Homemaker," considered themselves employed yet not working
because they were pregnant.

*Includes reasons such as pregnancy complications, jobs considered to be potentially
hazardous to both the mother and baby's health, and general belief that working while
pregnant adversely affects the baby's health.

The story that the numbers tell becomes even more complex when juxtaposed
with the number of women who were actually employed at the time of their interview.

Although sixteen women identified themselves as having occupations outside of the

home only eight of the sixteen women were actually working at the time of the interview.

83

The eight women who were not working cited a variety of reasons for their decision not
to work, ranging fiom pregnancy complications, belief that it was better for the health of
the baby, and their husbands' being their against working while pregnant. For five of the
eight women, the primary reason for not working while pregnant was that they believed
their job to be potentially too hazardous to the health of their baby. This belief crossed
the spectrum of jobs, fi'om working in food service to security. For example, Monica,
age 18 and single, waitressed at a bar before she became pregnant. She quit a couple of
months into her pregnancy because the smoke in the bar made her feel sick and she
worried about slipping on the wet floors behind the bar area. Gina, age 23 and single,
st0pped working as a housekeeper soon afier she found out she was pregnant for similar
reasons. The cleaning chemicals made her feel ill and it became harder and harder for
her to carry a vacuum or a bucket of water to wash floors. Finally, Emma, age 28 and
single, stopped working as a security guard when she was four months pregnant when she
began feel that she was no longer physically capable of carrying out her duties. She also
worried about her baby's safety if she should have to pursue an intruder or intervene in a
fight.

For all of the scenarios discussed above, women's use of Medicaid to cover their
prenatal care raises the fundamental question of how women find out about Medicaid in
the first place. Interestingly, none of the women in this study who were working outside
of the home indicated that they found out about Medicaid through their employers.
Similarly, few women found out about Medicaid through advertising, such as locally
televised public health messages. In general, women cited family, friends, and clinicians

as their primary source of information about Medicaid. The ways in which women found

84

out about Medicaid however, were often not quite so straightforward. Gina, age 23,
single, and the mother of two children explained:

The father of [the] kids was born and raised

on Welfare. He told me about it because my

mom and dad never had to be on it. Dad

said not to be on it for life, just to use it for

an emergency. 1 haven 't been able to get

back on my feet since.
When Gina was pregnant with her first child, a daughter, she was still covered by her
father's Blue Cross and Blue Shield policy. No longer covered by her father's policy
when she was pregnant with her second child and realizing that her parents did not have
any experience with the Medicaid system, she relied upon the father of her child to find
out about and navigate the system.

Gina's story raises the further question of how women navigate the process of
enrolling in Medicaid. Not surprisingly the majority of women in this study felt that a
friend or relative was instrumental in facilitating the application process because they
offered childcare, transportation to the public health department, or help filling out the
Medicaid application. For example, the first time Maria, age 21 and married, found out
she was pregnant, her sister-in-law told her about Medicaid and helped her get enrolled.
She drove Maria to the county health department, sat with her in the waiting room, and
helped her fill out all of the paperwork.

For many women the process of finding out about and choosing a clinic was
integrally tied to the process of finding out about and enrolling in Medicaid. For

example, Ruth, age 21, married, and pregnant with her first child was frustrated that she

had to use Medicaid for prenatal care despite the fact that both she and her husband were

85

employed full time. Their jobs in a bakery did not ofier any health benefits. When she
found out that she was pregnant, her sister, who had children of her own, told her to go to
the county health department to get help signing up for Medicaid. At the county health
department, Ruth received a list of physicians and clinics to choose from.

Sara, age 20, single, and pregnant for the first time found herself in a situation
similar to Ruth's. Covered under her father's private health insurance plan until she was
19, when Sara turned 20 she did not think about having health insurance until she found
out she was pregnant. Sara was working at a fast food restaurant that offered health
benefits, but she had to have worked there for a minimum of year to qualify for coverage.
Sara had been working at the restaurant for four months when she found out she was
pregnant. Convinced by her mother that she needed prenatal care, but realizing that she
could not pay for it out of pocket, she enrolled in Medicaid at her mother's urging. Sara's
mother was instrumental in telling her about Medicaid and helping her fill out the
Medicaid application. She also helped Sara choose the Hospital Clinic, where she had
had her own children, and sign up for W1C as well. Thus for Sara, the process of finding
out about and choosing a clinic was entwined with the process of finding out about and

enrolling in Medicaid and WIC.

86

Women's Social Resource Mmement and Stratem

Pregnancy and birth provide opportunities to examine ordinary health issues
specific to women in the context of health care institutions and household decision
making. As women go through pregnancy and birth they achieve access to health care
through a series of decisions and routines that I analyze as resource management. As
previously discussed, I argue that the resources that women draw upon through social and
economic networks — alliance building — form the basis of the strategies they develop
to gain access to biomedical care. The following interviews convey the complexity of
low-income Mexican American women's resource management elucidating the fluid
environment in which women actively and consciously select from and use a variety of
resources in creating strategies to achieve access to prenatal care.

Viewed in this context, women's resource management is not a single logical
construct that is closed and independent of other systems but rather one of options in
which a woman's strategy is shaped by social, economic, political and medical issues. As
the following interviews and discussion will illustrate, gender plays a significant role in
how women's resource management is shaped by the latter issues. By situating analysis
of women's resource management within a gender centered approach, I find that I can
advance the analysis of access to prenatal care firrther in terms of the ways in which the
social construction of gender roles shape women's access to and rmnagement of
resources. Consequently, the strategies that women develop to gain access to prenatal
care thus involve steps that are managed strategically based upon the broad scope of

women's social and economic resources.

87

Interview -—Maria

As Maria and I talk, her two-year-old son sits on the floor of the exam room
coloring in a Superman comic book. The interview had been interrupted earlier when she
was called in for her prenatal exam and I am hesitant to pick up where we left off since
Maria and her son have been at the clinic for the better part of the afternoon. Maria
reassures me, however, that she's in no hurry ——"It's boring at home," she exclaims with a
grirnace.

Maria, age 21, is seven months pregnant. Born and raised in the Lansing area, she
lives with her husband and their two-year-old son in an apartment on the West Side of
town. Maria finished 10th grade but then dropped out to get married when she found out
she was pregnant; her husband graduated fiom high school. This is Maria's third
pregnancy; she lost a set of twins when she miscarried halfway through her second
pregnancy.

Before her current pregnancy, Maria had been working at a grocery store stocking
merchandise. When I ask if she stopped working because she was pregnant she laughs
and after a drawn out "no" explains:

My husband got laid ofl— he used to work

at a warehouse. He 's been looking for a job

for awhile. I stopped because of personal

problems at home. I need to be at home.
As our conversation shifts towards what she will do after the baby is born Maria shrugs,
and explains:

He 's looking for a job but he doesn't want

me to work. He says it's not right —that the
husband should work and the Wife should be

88

at home. I'm hoping that it won 't be so
boring with a little baby around the house.

As with her two previous pregnancies, Maria relied upon Medicaid for her health
insurance. Although she worked at a grocery store through her previous pregnancies, she
pointed out that she could not afford to have the premium for the health insurance plan
offered by the store deducted fiom her paycheck. The first time Maria found out she was
pregnant her sister-in- law told her about Medicaid, and helped her get enrolled. She
drove Maria to the county health department, sat with her in the waiting room, and helped
her fill out all of the paperwork.

Maria has had prenatal care for all three of her pregnancies. With her first two
pregnancies she went to a public health clinic for her prenatal care and delivered at a
local hospital. Her sister-in- law drove her to her prenatal appointments at the public
health clinic and, since Maria lived across the street from the hospital, she walked over
when she went into labor. While she now has her own car, she felt that with a toddler to
carry around with her she should look for a clinic closer to her apartment -— so she

looked through the phone book and chose the clinic closest to her.

Interview — Rosie

Rosie, 19, had graduated from high school a year ago and was working as a
teacher's assistant at a nursery school. She lived with her parents on the south side of
Lansing but she and her boyfiiend, who lived in her neighborhood and attended a local
college, pooled their income to meet their financial needs. This was Rosie's first

pregnancy — she was five and a half months pregnant, worked full-time at the nursery

89

school, and planned to take the summer off when she her baby and then return to work in
the fill. She hoped that within a year or so she will be able to go to college herself. "I'll
work for a year after the baby is born. I just need to get past the first year with the baby
and then it will be easier for my mom to watch her whenI am at class."
When Rosie first found out she was pregnant, her parents told her that she needed

prenatal care and health insurance.

My mom had 4 kids. When she first found

out that I was pregnant she said, "We have

to get you some prenatal care. " Now I know

that it is good to have prenatal care so that

you can find out problems early and prevent

the long-term eflects.

My dad explained that we are low-income

and told me to go down to the health

department and apply for Medicaid. He

warned me that it would take a long time.
When Rosie first suspected that she was pregnant she went to a local public health clinic
for a pregnancy test. The nurse at the clinic explained that the clinic was really full and
suggested that she try an OB-Gyn clinic at a local hospital. Rosie agreed and the nurse
set up a prenatal appointment at and gave her one month's worth of prenatal "pills" to tide
her over. Using her mom's car, Rosie drove herself to her first prenatal exam, and
continued to do so through out her entire pregnancy. The social worker at the hospital-
based clinic helped her fill out an application for the WIC program.

As we discussed how Rosie first found out about the two clinics and services she

had used, and the steps she had taken to gain access to these services, she pointed out that

she had managed to find a physician and get into the WIC program but she was still

trying to become enrolled in Medicaid.

90

With Medicaid I feel like I'm running in
circles. My caseworker is not very helpful.
She's not specific about what I need to do —
she just sent me a form. She 's supposed to
help me. WIC has been very
accommodating. The people at the clinic
are good. I don 't have to wait too long and I
can always call with questions. They should
make Medicaid more easy to access for
people who need it. This is just taking too
long.

As we discuss Rosie's expectations about labor and birth, it becomes apparent that
she is preoccupied with the issue of who will be with her while she is in labor. Rosie
explains that she has thought a long time about this because her baby is due right around
finals time for her boyfriend. "If he is in a final, then my mom will drive me to the
hospital and stay with me. If not, then he will." Although Rosie says she is satisfied with
this plan, she explains that what she is really worried about is her mom. "My mom is
scared. She never had her husband with her when she was in labor. It was different
then." Rosie believes that her mother is afiaid because she didn't have any support when
she was giving birth to her children and that, as a result, it was a bad experience for her.
In light of her mother's fears about labor, Rosie contacted her aunt who works in the
radiology department at a local hospital. They decided that when Rosie goes into labor
she will "beep" her aunt who will then come to the hospital and explain everything to her

mom as it happens. Rosie points out, "My aunt is around patients all the time so she will

be able to help my mother and tell us what's going on."

91

Interview —-Theresa

Theresa, her three-year-old daughter Stacia, and I talked in an empty exam room
at the hospital-based clinic. At the time of our interview she was eight months pregnant.
Although she said she was engaged, Theresa, who is 18, lives with a girl fi'iend. The first
time Theresa was pregnant she was 15 years old and had just finished 9til grade. When
Theresa's mother found out that she was pregnant she kicked her out of the house and
told her she was on her own. Theresa dropped out of high school and moved in with a
her girl friend as the father "dropped out of the scene" as soon as he found out she was
pregnant. Three years later she is still living with the same friend.

Eventually Theresa and her mother repaired their relationship, although she did
not move back home, and her mother brought her to her prenatal visits at the clinic.
Despite this Theresa recalls that her first pregnancy was harder because she was by
herself. She explains,

This pregnancy is easier now because I

know more. When I was 15 and my Mom

kicked me out I didn’t know anything. Now I

have a house and a boyfriend for support.
On top of being older, having been pregnant once, and repairing her relationship with her
mother, Theresa could not emphasize enough how significant her fiance support has been
in helping her through her second pregnancy. Although he could not attend her prenatal
appointments with her, since he was working during the day, he lent her his truck so that

she could drive to her appointments. From Theresa's perspective, access to his truck, the

money he contributed towards her grocery bills, and his overall support made her second

92

pregnancy easier. She expected the birth to be different not only in that her fiance' would
drive her to the hospital but that he, as well as her mother, would coach her through labor.

Theresa had been working as a waitress in a bar before she was pregnant. The
smoky environment made her feel sick, and when she found out she was pregnant, she
decided to quit for both her own and the baby's health. Even when she was working as a
waitress, Theresa could not afiord private health insurance so, as with her first pregnancy,
she enrolled in Medicaid. Initially Theresa found out about Medicaid through the
receptionists and nurses at the hospital based clinic, who gave her the Medicaid
paperwork and directions to the county health department. Theresa didn't expect,
however, to be on Medicaid for much longer. Her fiance worked for a local construction
company delivering windows, siding, and doors. Since Blue Cross and Blue Shield
health insurance covered him through his job, they planned to add the baby to his policy.
When married, Theresa and Stacia would be covered under his plan as well.

Theresa's decision to use the hospital-based clinic was based on recommendations
fiom fiiends and her general belief that the OB-Gyn clinic was part of a good hospital.
Born and raised in Lansing, Theresa's mom as well as the friend she lives with, reside in
the same neighborhood as the community center based clinic. When asked why she did
not use the clinic at the community center she replied,

They just do food stuffr and clothing for
people. [The hospital based clinic] has
more stufif It seems more professional.

Since Theresa had used the Hospital Clinic when she was pregnant with Stacia, I
asked her how she chose her physician for both her first and current pregnancies. She

couldn't remember how she "got her doctor" the first time. She explained, however, the

93

second time she was asked by the intake nurse if she preferred to have a man or a woman
as her physician. Theresa indicated that she didn't really care who she got as long as it
was a "lady." When asked why it was important for her to have a woman physician she

explained that she wanted a "lady" because she would feel more comfortable with her.

Discussion

Examining low-income Mexican American women's resource management from
the perspective of the individual illustrates the centrality of gender in analyzing the
political economy of everyday issues, such as employment or unemployment,
transportation, childcare, and household composition, in the strategies women develop to
gain access to health care during pregnancy and birth. The dynamic relationship between
employment and health insurance illustrate a multi-faceted view of access in which
women's strategies address weighing the costs and benefits of insurance premiums for
private health insurance; working in jobs that do not offer health benefits; and highlight
the intersection of martial status and qualifying for spousal benefits. A gender-centered
perspective of resource management thus illustrates that women's strategies articulate
with the specific characteristics of the economic situation of their households.

In the first case study, the dynamic relationship between employment and health
insurance is illustrated by Maria's realization that she would not have enough money to
sustain her family if she had the health insurance premium deducted from her paycheck
each month. This cost/benefit analysis was a determining factor in her decision to use
Medicaid when she was pregnant. In turn, Maria's sister-in-law became a significant

resource in managing access to health care for she told Maria about Medicaid, helped her

94

to get enrolled, and then drove Maria to her prenatal appointments at the public health
clinic. Three pregnancies later, transportation and childcare still remain a central issue in
Maria's access to health care. Although she now owns her own car, her choice of what
clinic to use for prenatal care was influenced by location and the child she had to bring
with her to her appointments. As she pointed out, she went through the phone book and
chose the clinic closest to her.

Maria's husband's expectations about her role as a wife and mother further
highlight a gender-centered political economy which structures their household in such a
way that she did not work outside of the home even though her husband was
unemployed. While Maria's previous job did not offer her any viable health insurance
benefits, working outside of her home gave her access to a larger social network she
could rely upon for child care and transportation needs. In a pinch she could ask a friend
from work to watch her little boy for a couple of hours or to give her a ride to an
appointment. Although her sister-in-law was able to fill this gap for her to some extent,
and she now has her own care, Maria's access to social resources was limited. As a
result, the location of the clinic and the childcare became primary issues that influenced
her strategies in managing access to health care services.

Rosie's strategy to gain access to prenatal care was fundamentally shaped by the
political economy of her work situation in that the child care center where she worked did
not offer employees health insurance. In Rosie's case, her mother and fither were
fundamental resources in gaining access to health care during her pregrmncy. Although
Rosie went to the Public Health Clinic on her own initiative when she first suspected that

she was pregnant and the nurse set up a prenatal appointment for her at the Hospital

95

Clinic, her mother's statement that she needed prenatal care validated for Rosie the
necessity of prenatal care. Rosie's father's explanation that they were "low-income"
fundamentally shaped Rosie's strategy in that he identified a source of insurance, a
physical location for her to gain access to it, and an intimation of what the process would
entail.

The role gender issues play in influencing women's access to health care is also
evidenced by the strategy that Rosie developed to address her mother's fears about labor.
Aware that her mother might have to be her labor coach if her boyfriend was in the
middle of a final exam, Rosie realized that she needed to come up with a viable plan to
ease her mother's fears. Having deduced that her mother's fears were rooted in her own
childbirth experiences —- in which she did not have any labor support from her own
family — Rosie arranged to have her aunt, who worked in a medical setting, coach her
mother when Rosie was in labor. From Rosie's perspective, the need for a plan to deal
with her mother's fears burgeoned fiom an event shaped by gender. As Rosie stated,
"She [Rosie's mother] never had her husband with her when she was in labor. It was
different then." Aside fi'om necessitating this plan, her mother's labor experiences also
led Rosie to decide that she would have her boyfriend with her while she labored. This
decision illustrates another way in which gender shaped the resources Rosie managed in

managing access to health care.

Finally, Theresa's situation can be used to analyze a gender-centered perspective

0f polit ical economy in which she tied her health care strategy to her marital status.
Having decided not to work at the bar while she was pregnant because of her concern for

her own health, as well as her baby's, Theresa enrolled in Medicaid. She anticipated

96

however, that she would not be on Medicaid for long as she and her fiancé were soon to
be married. Once married she, as well as her daughter Stacia, would be eligible for
coverage on her husband's health insurance plan. Theresa's choice of clinic similarly
evidences the political economy of her health care strategy. Although she lived in the
same neighborhood as the Latino Community Center Clinic, Theresa chose the Hospital
Clinic because it seemed more "professional." As Theresa in essence articulated, she
perceived the Latino Community Center Clinic, which also handed out food and clothing,
as being for "poor" people. In contrast, Theresa interpreted the primarily clinical services
provided by the Hospital Clinic as more professional —meaning that the Hospital Clinic
had more modern equipment and "better" staff.

While Theresa's plan to gain access to health insurance through her future
husband is clearly an example of a gender-centered political economy of access; her
strategy was influenced by gender in other ways as well. Theresa perceived pregnancy as
being easier the second time around not only because she was now "experienced" but
because of the support she received from her fiancee with regard to money, the use of his
truck, and moral support. Furthermore, Theresa's plan to have her fiancee drive her to the
hospital and coach her through labor introduced an element of support that Theresa

perceived as being gender-centered since her fiancee would add a "male" presence.
Gender also played a similar role in Theresa's choice of physician. When asked if

she preferred a man or a woman as her physician Theresa chose a "lady." Her choice

was not influenced by the prospective physician's qualifications, approach to prenatal

care or childbirth, or personality, but rather was solely based upon gender. Theresa

97

assumed that she would feel more comfortable discussing her pregnancy and being
examined by a woman rather than a nun.

Pregnancy and birth are events that are both commonplace to clinic personnel and
unique everyday experiences for pregnant women. Giddens (1979) developed a concept
of "tacit," or "practical knowledge," to describe the ways in which people go through life
using fimiliar assumptions to deals with various situations where conscious decision
making is carried out. In this analysis I use the concept of tacit knowledge to address
resources women draw upon in creating new strategies to manage access to health care
services during pregnancy and birth Maria, Rosie, and Theresa's everyday experiences
illustrate that there are steps involved in access health care services that women
strategically manage based upon the broad scope of their economic and social resources.
As I will discuss in the following chapter, these complex pathways, which are structured
by gender, political, and economic factors, are in stark contrast to clinic personnel's

perception of the decision making process involved in low-income Mexican American

women's efforts to gain access to prenatal care.

98

Endnotes

 

' In interviews, both women seeking care and clinic personnel used the turn "baby" to refer to both a fetus
as well as a baby that was already born.

99

Chapter 5: Clinic Personnel's Views of Women's Access to Prenatal
Care

As low-income Mexican American women go through pregnancy and birth they
achieve access to prenatal care through a series of decisions and routines that I analyze as
social resource management. As discussed in the previous chapter, the resorn'ces that
women draw upon in the form of fimily, friends, and co-workers as social networks of
information and support, help them to address issues related to childcare, transportation,
working both in and outside of the home, and unemployment in facilitating access to
prenatal care. The strategies tlmt low-income Mexican American women develop in this
process thus involve steps, or alliance building, that are managed strategically based upon
the broad scope of their social resources.

Clinic personnel, and their organizations, in this study often conceptualized access
to health services in terms of socioeconomic issues however, their understanding of the
elements involved in gaining access to prenatal care did not encompass women's social
resource management. Whereas clinic personnel identified transportation, lack of health
insurance, and the inability to pay for needed medical care as socioeconomic issues that
low-income women must overcome in achieving access to care, they viewed these issues
as isolated events, or barriers, rather than a series of interconnected issues that women
addressed by drawing upon the social resources available to them. Perceived in isolation,
clinic personnel consequently concluded that barriers, such as the aforementioned, had
been successfully overcome once women attended a clinic appointment and enrolled in
Medicaid. In the first half of this chapter I analyze clinic personnel's perspectives of low-

income Mexican American women's access to prenatal care with respect to their

100

understanding of why women obtain prenatal care, how they find out about and choose a
clinic, and how women enroll in Medicaid. In doing so, my goal is to examine the
common themes of clinic personnel's perceptions.

Clinic personnel in this study often viewed socioeconomic barriers inhibiting low-
income women's access to prenatal care in the context of ethnicity. Structured in terms of
working within the limits of their clients' financial constraints, clinic personnel working
at "free," "sliding scale," and "public" clinics, such as the ones in this study, often
equated low-income with belonging to an ethnic minority. For the most part, this was
due to the fict that the majority of low-income women clinic personnel served in their
clinics belonged to an ethnic minority. As a result, many clinic personnel in this study
viewed ethnicity as an integral factor that shaped low-income Mexican American
women's access to prenatal care. Consequently, in the second half of the chapter, I
examine how gender, socioeconomic issues, and belonging to an ethnic minority
influence clinic personnel understanding of women's social resource management and

strategies to gain access to prenatal care.

Clinic Personnel's Perspectives
Why Women Obtain Prenatal Care

In general clinic personnel, like their patients, cited the health of the baby as the
primary reason why women obtained prenatal care (see figure 5.1). This response,
however, is not as straightforward as it may seem. Many clinic personnel linked
women's concern about the health of their baby with specific health problems or

complications that their patients experienced during their pregnancy.

101

Number of Responses

Figure 5.1
Clinic Personnel's Views on Why Women Obtain Prenatal Care
N, number of responses = 18 fiom 15 Clinic Personnel

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10 m
9 . _
I Clerical Staff
8 ,_ __fim, ___ a Clinical Nurse tn,"
I MD/Nurse Practitioner
7 ' ~
6 ~f—
5 I
4 :—
3 I
2 L
1 ....................... _ _ _
0 . . _ ,
Health of the Matters The Right F933 3'3““ Establish Find 0,,
Buy ' Health Thing to 00 W Connection with a Sex
Ham «Bury

For example, Margarita, a nurse practitioner at the Latino Community Center
Clinic indicated that many of the women she saw did not think that prenatal care was
important. "Health is the last thing on their mind. They're more concerned with their
children or getting food for the next day." In Margarita's view, women didn't think about
prenatal care until a specific complication arose and then they came into the clinic for
help. The health of their baby thus becomes their primary reason for obtaining prenatal
care.

Margarita's explanation for women's concern with the health of their baby

highlights an interesting class dichotomy in clinic personnel's overall responses to the

102

question of why women seek prenatal care. Clinic nurses and clerical staff strongly
believed that a mother's concern for her baby's health was a major motivating fictor in
women's decision to obtain prenatal care. While some of the clinic nurses and one
provider from the MD/Nurse Practitioner group believed that women sought prenatal care
to establish a connection with the hospital at which they would give birth none of the
clerical staff responded in this manner. I believe that this dichotomy is due in part to
Clinic Nurses and IVHD/Nurse Practitioners' educational backgrounds and roles as health
care providers, both of which brought them in contact with the hospital itself.
Consequently, their vision of health care access encompassed a broader locale than the
prenatal clinic. Clinic Nurses and MD/Nurse Practitioners were also strong advocates of
childbirth education classes yet realized that the majority of their patients could not
afford to participate in such classes. Their belief that women sought prenatal care to
establish a connection with a hospital may have also been founded in their support of
these courses, which are oriented around hospitalized labor and delivery.

Clinic personnel often cited secondary motivations for why women obtained
prenatal care as well. These secondary motivations ran the gamut, ranging fi'om finding
out the sex of the baby to having an "in" to delivering at a hospital. As one Family Nurse
Practitioner explained:

Some don 't think they need it [prenatal care]
because it's not important — especially if
they 've had a healthy baby. They know

they 're going to go to the hospital [to have

the baby] and they have to hook in [to the

system] somehow. [T anya, Public Health
Clinic]

103

The latter of these secondary motivations illuminates the more complex nature of the
strategies women develop to gain access to health care during pregnancy and birth

Many clinic personnel expressed the belief that women do not really understand why
prenatal care is important, especially if they have a healthy and uneventfirl pregnancy.
Despite efforts to explain its importance and the procedures involved in prenatal care,
many clinic personnel realized that to patients it might not seem as though much is really
being done. One aspect of prenatal care that clinic personnel felt patients did grasp
however, was the ultrasound. Clinic personnel felt that whereas they placed the value of
the ultrasound squarely on establishing the health of the baby, patients viewed it solely as
a tool for determining the sex of their baby. Clinic personnel thus viewed the ultrasound

as a powerful secondary motivation in women's reasons for obtaining prenatal care.

How Women Find Out About and Choose a Clinic

In general clinic personnel in this study believed that women found out about
prenatal care from fiiends and family, and more specifically, fi'om their mothers (see
Figure 5.2). In these instances clinic personnel envisioned scenarios in which their
patient's mothers or sisters had used the clinic to give birth to their own children. Clinic
personnel often referred to these patients as "repeat customers" as they usually belonged
to fimilies that frequented the clinic on a regular basis — year after year.

Clinic personnel's ideas about how women found out about prenatal care were
closely linked to their perceptions of how and why women chose to patronize a clinic.
Generally, they surmised that women found out about a clinic based on information

gathered fi'om fi'iends and fimily. Clinic personnel felt however, that a woman's actual

104

decision to use a particular clinic was also influenced by cost, location, and her own
familiarity with the clinic. The clinic personnel who articulated economic fictors women
might consider in choosing a clinic stressed the importance of a "free clinic" in which
Figure 5.2
Clinic Personnel's Explanations of How Women

Find Out About Prenatal Care
N, number of responses = 30 from 15 Clinic Personnel

 

 

 

I Clerical Staff
5 Clinic Nurse
I MDINurse Practitioner

 

 

 

 

 

 

 

 

 

   

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women knew that they would not have to pay for their care regardless of whether they
had Medicaid coverage. They similarly discussed the implications of a clinic's location,
realizing that a woman might choose one clinic over another if she could walk or easily

take the bus to a clinic. Finally, clinic personnel realized that a. women's familiarity with

105

a clinic also contributed to the decision making process as well. In this sense, a woman
might be more inclined to obtain prenatal care at a clinic she also used for gynecological
care, as she would be fimiliar with the staff, routines, and the clinic itself. In particular
this was true of the Latino Community Center Clinic, which was essentially a general
practice. Many of the women who attended their prenatal clinic on Thursday mornings

had been seen by other clinic personnel for a variety of health related concerns.

Finding Out about and Enrolling In Medicaid

As did the women in this study, clinic personnel similarly perceived gaining
access to health care as being integrally linked to the process of finding out about and
enrolling in Medicaid. This belief was due mostly to the fact that clinic personnel viewed
family, fiiends, and clinics as the main purveyors of information about prenatal care as
well as Medicaid. Despite this similarity, clinic personnel viewed the process of finding
out about and enrolling in Medicaid much differently than their clients.

As previously discussed, women often felt that enrolling in Medicaid was a
cumbersome process which involved travelling to the county health department, figuring
out how to fill out application forms, miscommunication with Medicaid case workers,
and a lengthy enrollment period. As Rosie explained in Chapter 4, she had managed to
find a physician and enroll in the WIC program yet five and a half months into her
pregnancy she was still waiting to have her application approved by Medicaid. In
contrast, clinic personnel overlooked the process involved in enrolling in Medicaid and
instead viewed it as a foregone conclusion. While they recognized that travelling to the

county health department to enroll in Medicaid and that the process itself was

106

complicated and lengthy were both issues that inhibited the enrollment process, clinic
personnel presumed that women would overcome these "barriers" to have the benefit of
Medicaid coverage.

Although many clinic personnel understood there to be barriers, such as the ones
mentioned above, inhibiting low-income Mexican American women's access to Medicaid
they were almost evenly split with regard to the notion that Medicaid offered low-income
women coverage comparable to that of a private health insurance plan.

Figure 5.3

Quality of Coverage: Medicaid vs. Private Health Insurance
N, number of responses = 16 fi'om 15 Clinic Personnel

19%

No Difference

31%

 

Private Health Insurance

Provides Better Coverage

37%

Medca‘d Provides
Better Coverage

 

The issue of whether Medicaid offers better or worse coverage than private
insurance at first may seem irrelevant to low-income women's access to prenatal care
however it illuminates a basic premise that many clinic staff espouse — that low-income

women should be thankfirl for the coverage that Medicaid provides. As the following

107

vignettes illustrate, clinic personnel often felt that Medicaid offered excellent coverage
and access to a variety of resources. As a result, clinic personnel concluded that women
on Medicaid had no reason to complain about the care they receive and, furthermore,
should be thankful for it.

Once they [women] get in they have

wonderful coverage. I haven ’t noticed

anything they can 't have — ultrasound etc.

[ Cory, Clinic Nurse, Public Health Clinic]

It [Medicaid] covers everything and then the

baby for two years. [Diane, Reception

Clerk, Public Health Clinic]

1 think so, personally, but not a lot of the

clients do. For example, Medicaid only

covers one ultrasound — they want another

one to find out the sex. Their expectation is

higher than our standard. [ Mindy, Clinic

Nurse, Public Health Clinic]

Discussion with clinic personnel about women's expectations of Medicaid
coverage and prenatal care always included speculation about why women did not have
private health insurance in the first place. Despite espousing the argument that women
should be "thankful" and feel "lucky" for Medicaid coverage, clinic personnel readily
placed a significant portion of the burden of the underinsured and non-insured upon
employers. As figure 5.4 illustrates, the majority of clinic personnel interviewed believed
that one of the main reasons women did not have private health insurance was because
their employers did not offer health benefits or women could not afford to pay the

premium for private coverage. As such, clinic personnel conceptualized their clients as

being more than "low-income" —— using the term "working poor" to describe women who

108

held steady jobs but yet did not make enough money to pay for even the basic necessities

of life.

Figure 5.4
Why Clients Do Not Have Health Insurance: Clinic Personnel's Explanations
N, number of responses = 23 from 15 clinic personnel

12

 

 

 

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Working on Education Provided Married Period at
Welfare by Job“ Job

"‘ Includes explanations that health insurance was not a benefit provided by an employer
as well as instances where a woman was not able to afford having the insurance premium
deducted from her paycheck.

Figure 5.4 also illustrates however, that a large number of clinic personnel also

believed that women did not have private health insurance because they were not

working. Interestingly, this belief was articulated by only clinic nurses and clerical staff.

109

Clinical nurses, however, were carefirl to distinguish between "not working" and
"unemployed" for they realized that many women considered themselves "employed" yet
they were not working during their pregnancy. Women in the "not working" category
thus not only held a job before they were pregnant they intended to return to their job, or
a similar one with a different employer, after their baby was born.

Despite consciously distinguishing between "not working" and "unemployed"
clinic personnel, both clinical nurses and clerical staff, were not very sympathetic of the
notion that women did not work when they were pregnant. For the most part, clinic
personnel felt that women made the conscious decision not to work while they were
pregnant and, as a result, had to rely upon Medicaid. Realizing that most women,
working poor or not, only have 12 weeks of maternity leave after the birth of a child,
clinic personnel thought that it was unrealistic of women, low-income women to boot, to
stop working when they were pregnant. Karen, a Registered Nurse at the Hospital Clinic,
explained that many women asked for work releases or excuses because they were

pregnant. She told them that they had to "rise above the pain and just do it."

Clinic Personnel's Perspectives

Analyzing clinic personnel's perceptions of low-income Mexican American
women's expectations of and beliefs about access to prenatal care, illuminates how
variables such as gender, politics and economics and belonging to an ethnic minority
influence clinic personnel's perceptions of health care access. In the following case
studies, drawn from interviews with clinic personnel, I present the everyday experiences

of clinic personnel actively navigating a health care system in examining how barriers

110

related gender and politics and economics influence clinic personnel's perceptions of
access. As such, interviews with clinic personnel show that the quality, availability, and
process of accessing health care articulates with clinic personnel's preconceived notions

of what it means to be poor, female, and Mexican American.

Interview — Cory

Cory, a Clinic Nurse at the Hospital Clinic, and I met in her office for our
interview. A petite woman with boundless amounts of energy, she always found time to
stop in the hall and chat with me whenever I was at the clinic. Cory often joked that she
"did it backwards" — meaning that she got married and raised a fimily and then went to
college and graduate school in her late thirties. Married and now the mother of two adult
children, she has earned a number of nursing degrees: BSN, RN, and LPN. At the time
of our interview, Cory had worked at the Hospital Clinic for 10 of the 15 years she had
been a nurse. She chose to become a nurse because many of the women in her fimily
had been nurses.

While Cory articulated responses commonly expressed by her colleagues about
how women find out about prenatal care and choose a clinic, Medicaid was a central
theme that encompassed her perspective of women's access to prenatal care. She
similarly speculated that women found out about prenatal care through their friends and
family and that women's primary motivation for obtaining prenatal care was to monitor
their pregnancy. From her perspective women believe that if " they have the testing then

they think that their pregnancy will be o.k." It was Cory's belief however, that finding

111

out about prenatal care was findamentally linked with finding out about Medicaid. In
her view, the process was one and the same.

Women find out about Medicaid by word of

mouth through friends and it is common

knowledge. Iheyfind out about [our clinic]

through the Family Independence Agency,
and via word of mouth through friends and

family.

Cory's belief of the integral link between finding out about prenatal care and
Medicaid access seemed to indicate a presumption on her part that the process of actually
gaining access to a clinic for prenatal care was similarly straightforward. With this in
mind I asked her if she thought women faced any problems in finding and using a clinic.
In response she speculated about "late care" — women who do not begin prenatal care
until late in their pregnancy. Although she was not sure what barriers women might face,
she was sure that "late care" was the result of problems in signing up for Medicaid:

Late care. They [women] put it ofl so I 'm
sure there 's barriers. It used to be that
people were embarrassed to be on Medicaid
but things have changed. They 've [her
clients] . . . attitudes have changed.
With the issue of "late care" in mind, Cory went on to discuss the care women receive
upon enrolling in Medicaid:
Once they get it they have wonderful
coverage. I haven 't noticed anything they
can 't have — ultrasounds, referrals, tests.
The significance of Cory's Medicaid theme throughout our discussion of how

women gain access to prenatal care became apparent towards the end of the interview

when she commented that hardly any of the women she saw in the clinic had private

112

health insurance. Curious as to why she had raised this issue I asked her if she believed
that women on Medicaid received different care from women with private health
insurance. Cory hedged in her response, explaining that while it might be true at other
clinics it was definitely not the case at her clinic. She went on to point out that women
seen at the Hospital Clinic get much better care than women with private insurance,
explaining that "[T]hey get better care [here] because they get more education, they see a
nutritionist, and they have access to a social worker." As an after thought Cory added
that women on Medicaid were perceived differently by clinic personnel in general since
the care that women received was thought of as a gift. "We're paying for them to have

babies."

Interview — Diane

Diane worked as a Clinic receptionist at the front desk of the Public Health Clinic.
Since three other women occupied the front desk area Diane and I met in the clinic
personnel's lounge at the back of the clinic. In her late fifties, Diane was a matronly
woman who radiated an air of obstinacy and an attitude that implied one should be
thankful for her help. Born and raised in the greater Lansing area she began working for
the Public Health Clinic when she graduated from high school. Now, the divorced
mother of four adult children, she has been employed with the Public Health Clinic for 21
years. As Diane explained, "I was a housewife with a station wagon before I started
working at the [Public Health Clinic]." At 38 her husband divorced her and through a

friend she found out about a part time job at the Public Health Clinic as a front desk

113

receptionist. Eventually she was offered a full time position and she took the job because
she need the money and the benefits.

Diane asserted that women found out about prenatal care when they came in for a
pregnancy test, at which point clinic staff encourage women to get early prenatal care.
She explained that while some women are non-compliant, others will get it if they care.
Curious as to Diane's definition of "non-compliant" I asked her what she meant by this
statement. She replied, "They're non-complaint because they just don't care about their
health and the health of their baby."

As in many other interviews with clinic [personnel the locus of our discussion
about health care access seemed to be centered in the clinic. In an effort to redirect
Diane's attention to issues women might fice before they even entered the clinic I asked
her how she thought women found out about her particular clinic. Again, she responded
similarly to her colleagues stating that women found out about the public health clinic
fi'om friends and family, especially ones who had used the clinic. When pressed, Diane
could not, however, think of any barriers that might prevent women fi'om finding out
about or using the clinic for prenatal care. She pointed out that there were lots of
advertisements about the clinic and prenatal care. Furthermore, she asserted,

Women need a "clinical test" [pregnancy
test] to apply for Medicaid so there is
always early access.

Diane thought that women found out about Medicaid in a similar fishion —
primarily through fimily members but also through social networks and the public health
clinic. She reasoned that if a mother was on Medicaid then her daughter would know

about it if she didn't have any health insurance. Again, Diane did not know of any

114

barriers that might inhibit women's access to Medicaid. After thinking for a bit however
she tentatively suggested that perhaps language might be a barrier but she was hesitant to
endorse this as a barrier since refugee services provided an interpreter for women who do
not speak English. From her point of view Diane believed that language might be a
deterrent at first but not for a long period of time if the woman really wanted care. As we
continued to talk about the problems language might present, specifically for Mexican
American women who might not speak English, it became apparent that Diane made a
clear distinction between a "barrier" and "deterrent" — a banier kept people away
whereas a deterrent was an obstacle that could be overcome. To illustrate this distinction
Diane further explained:

We have stafl here that speak Spanish, there

are interpreters or they bring a family

member [who speaks English ."

In conjunction with our discussion about barriers that inhibit women's access to
prenatal care, Diane explained that in her view Medicaid alleviated many of the barriers
women might be ficed with since " it covers everything and then the baby for 2 years
through the child care clinic." Although postpartum care is not covered by Medicaid
Diane pointed out that the public health clinic has a sliding fee scale for postpartum care
thus, in her mind, alleviating any deterrent there might be. As an aside Diane explained
that outreach programs had done a lot for women with regard to obtaining prenatal care
— "We used to confront these women because they didn't think they needed it."

Eventually Diane's lecture on how Medicaid alleviated barriers to health care
centered in on a central theme of clinical access — that women should be thankful for the

services they received through Medicaid and the public health clinic. As did many of her

115

colleagues, she too pointed out that in "her clinic" women had access to a nutritionist, a
social worker and much more regardless of whether they used Medicaid or private
insurance. Furthermore, she argued that women seen in her clinic had access to more
services than women with private insurance who are seen in "private" doctors' offices.
To illustrate her point Diane used her own prenatal care experiences, covered under her
husband's private health insurance policy, as an example. Diane explained that when she
was pregnant she had to go to many different places for her prenatal care — a laboratory
on one side of town for blood tests, a pharmacy on the other side of town to have
prescriptions filled, and her doctor's office, in the middle of town, for prenatal visits —
whereas women at the public health clinic can receive all of these services in one
location. Diane's belief that the public health clinic, and Medicaid, afforded a woman
better care was firrther validated by a medical school resident on rotation at the clinic
who echoed the same opinion. In closing, Diane articulated that the "one stop shopping"
provided by the clinic was especially important since almost all of the women seen in the

clinic were "non-compliant" and "low-income."

Discussion

While the views and perspectives expressed in the latter two interviews address
only two clinic personnel's thoughts on the strategies low-income Mexican American
women employ to gain access to prenatal care, they highlight aspects of a gender
centered approach to political and economic issues that were common themes in many of
my interviews with clinic personnel. As I illustrate in both of these case studies, gender,

politics and economics shaped the decisions each health care provider made in choosing

116

her profession. In turn, gender, politics and economics similarly figure into each clinic
personnel's perception that health care access and Medicaid access are one and the same.

The pathways that led Cory and Diane to a career in health care were not unique
among the clinic personnel interviewed in this study. Many clinic personnel found
themselves entering the work force after they had married and raised their children.
Clinic personnel's average age was 43. Cory and Diane's stories thus illustrate how
gender roles shaped their choice of career as well as their motivation to enter the work
force. In Cory's case, gender informed her role as a wife and mother first, and then as a
nurse later. Cory was raised with the expectation that she would marry and fulfill her
roles as a wife and mother before choosing a career outside of the home for herself. Once
her children had grown and moved out of the house she then began considering her career
options. Using the social resources available to her through her fimily network she
talked with other women in her fimily, the majority of whom were nurses. As a result
Cory too decided to pursue a career in nursing. Gender thus shaped Cory's decision to
pursue a career outside of her home and her choice of career as well.

Gender similarly shaped Diane's career path in that she too firlfilled expectations
that she marry and stay at home while she raised her children. Gender issues similarly
shaped her entrance into the work force in that had her husband not divorced her she
would not have found it necessary to work outside of the home. Diane indicated that she
was satisfied with her previous role as a wife and mother in her statement — "I was a
housewife with a station wagon before I started working at the [Public Health Clinic]."
Relying upon her social network, a friend told her about a job with the public health

clinic as a receptionist. As Diane indicated, her change in marital status and the fact the

117

job with the public health clinic offered her both the income she needed as well as health
benefits motivated her career choice. To this extent, political and economic issues also
played a role in Diane's entrance into the work force as she needed to earn enough money
to support herself and her four children.

Political and economic issues fundamentally shaped both Cory and Diane's views
of health care access as they equated health care access with Medicaid access. Again,
this was a theme commonly expressed by many clinic personnel I interviewed. For Cory
gaining access to prenatal care was integrally linked to Medicaid with regard to the
process of finding out about and choosing a clinic. As Cory indicated in our interview
she believed that women found out about Medicaid from friends and fimily and in the
process they also found out about the clinics available to them for prenatal care. Cory's
discussion of "late care" firrther illustrates how politics and economics shape clinic
personnel's view of health care access. Although she was not able to identify any barriers
that might inhibit women's access to prenatal care or Medicaid Cory perceived the wait to
obtain prenatal care — "late care"— as the result of a woman's hesitation to enroll in
Medicaid due to a stigma associated with being a Medicaid recipient.

Diane expressed similar views as Cory about the link between health care access
and Medicaid. Her statement that women needed a "clinical test" [pregnancy test] to
apply for Medicaid clearly articulated the practical linkage of these two components in
that Diane concluded that a pregnancy test for Medicaid is an guarantee of early access to
prenatal care. Like Cory, Diane reasoned that women found out about prenatal care in

the process of finding out about Medicaid. However, Diane took this rationale one step

118

further in her presumption that a daughter would automatically know about Medicaid and
the resources available to her if her mother was on Medicaid.

Both Cory and Diane expressed that they felt women on Medicaid received better
care through Medicaid than they would if covered by a private health insurance plan.
Both supported this argument by citing the variety of resources available to women at
their clinics: a nutritionist, a social worker and much more regardless of whether they
used Medicaid or private insurance. In essence Cory and Diane were presenting a
politics and economics argument that highlighted the attributes of their clinics and, from
their points of view, alleviated any barriers that could possibly inhibit women's access to
prenatal care. Diane's argument that women seen in her clinic had access to more
services than women with private insurance, who were seen in "private" doctors' offices,
illustrates this point. By drawing upon her own prenatal care experiences, Diane'
experiences portray the political and economic nature of having to travel from one
provider to another (the laboratory, the pharmacy, and her doctor's office) to comply with
her prenatal care regime. Diane's resulting advocacy of the "one-stop-shopping" offered
by the public health clinic thus articulates a political and economic premise of health care

access that precludes barriers that might inhibit women's access to prenatal care.

119

Chapter 6: Cultural Competency

In this study, clinic personnel's discussions of low-income Mexican American
women's access to prenatal care revolved around two central themes: barriers and
ethnicity. While many clinic personnel recognized that barriers and ethnicity
simultaneously shaped the ways in which women gained access to prenatal care,
oftentimes portraying the two as synonymous, the majority of clinic personnel were not
able to give examples of barriers, other than language, specific to Mexican American
women's experiences. Shifting the focus away fi'om barriers however, to a broader
discussion of women's use of clinical services and resources, elicited explanations that
espoused the ethnic basis of clinic personnel's view of access. As I illustrate in the first
half of this chapter, clinic personnel's discussions about how low-income Mexican
American women find out about and use Medicaid, problems that might inhibit or restrict
women's use of prenatal clinics, and reasons why women might not work during
pregnancy highlight the integral way in which ethnicity shapes their understanding of
access.

The complex nature of clinic personnel's inability, or unwillingness, to recognize
the ethnic basis of their explanations of access as barriers is, in part, due to two prevailing
public health conceptual fiameworks. The first, as I argue in the first half of this chapter,
is that public health and health care research has traditionally conceptualized "access"
and "barriers" to health care in terms of "health care utilization" — meaning the kinds of

services provided, the location of service, who provides and uses the service etc (Loue,

120

1999). As such, clinic personnel perceive barriers in terms of patients' contact with a
physician or clinic.

The second conceptual fi'amework, which advocates the need for clinic personnel
to be aware of their patient's ethnicity and cultural beliefs, is cultural competency — a
process through which clinic personnel were taught what behavior to expect of and how
to frame their interactions with different ethnic populations. As such, manuals used in
cultural competency training offer portraits of ethnic minority groups, such as African
American, Asian, Hispanic, and Native American, that are intended to give clinic
personnel an overview of their respective demographic, socioeconomic, and cultural
beliefs and practices. In turn, clinic personnel are taught that recognizing the cultural
basis of minority populations' beliefs about health and illness will help them to better
facilitate their interactions with patients who belong to an ethnic minority. A major goal
in cultural competency training is thus to help clinic personnel, who previously perceived
ethnic and cultural beliefs about health and illness (i.e., folk medicine) as a barrier to
health care, view cultural beliefs as a positive resource that they can capitalize upon when
treating patients who belong to an ethnic minority.

The majority of clinic personnel in this study had received some sort of cultural
competency training either through the organizations they worked for or through their
schooling. As I illustrate in the second half of this chapter, the ethnic basis of clinic
personnel's explanations of low-income Mexican American women's access to prenatal
care and their understanding of what it means to belong to an ethnic minority were
fundamentally premised upon the conceptual fiamework of cultural competency. Their

reliance upon this fi'amework in part explains clinic personnel's inability to understand

121

how why they equate socioeconomic barriers with ethnicity. I argue that using the
concept of ethnicity in this manner ultimately does a great disservice to clinic personnel's
understanding of how low-income populations gain access to health care services for it
reifies what it means to belong to an ethnic minority. As such, I examine how cultural
competency training leads clinic personnel to conclude that ethnicity, rather than
women's resource management, plays a more significant role in shaping low-income

Mexican American women's access to prenatal care.

Obtaining Prenatal Care: Barriers and Ethnicity

 

Clinic personnel in this study identified socioeconomic issues, such as
transportation problems and lack of health insurance, that women must overcome in
gaining access to prenatal care. As discussed in the previous chapter, clinic personnel
often conceptualized these " issues" as isolated events or barriers rather than viewing them
as a series of interconnected issues that women addressed through the social and
economic resources available to them. As such, clinic personnel perceived barriers
inhibiting low-income Mexican American women's access to prenatal care in terms of
their contact with a physician or prenatal clinic. This distinction is significant for it
addresses a fundamental premise of clinic personnel's conceptualization and use of the
term "barrier." As 1 illustrate in the following discussion, clinic personnel's focus on
barriers presumed that access to prenatal care was a given since their organizations —
clinics —— provided a variety of services and resources that they perceived as being
readily available to women. In identifying barriers clinic personnel referred to women's

individual characteristics and their social environments, such as socioeconomic status,

122

culture, and ethnicity, that inhibited their entry into the clinic or use of clinic services and
resources.

Many clinic personnel in this study did not distinguish between socioeconomic
issues and ethnicity in their discussion of barriers to gaining entry to a prenatal clinic.
Rather, they perceived ethnicity and socioeconomic status as integrally entwined. This
was mostly due to the fict that the majority of the low-income women they served
belonged to an ethnic minority. As such, clinic personnel often equated being poor with
belong to an ethnic minority. Consequently, however, many clinic personnel concluded
that ethnicity, or cultural beliefs, not only fundamentally shaped women's access to

prenatal care but was in and of itself a barrier that inhibited their use of prenatal services.

Socioeconomic Barriers and the Ethnic Context

In response to the question "Are there any barriers women might encounter in
finding out about and/or using prenatal care," clinic personnel articulated a number of
socioeconomic barriers ranging fiom fear that the clinic would not accept Medicaid to
laziness. As figure 6.1 illustrates however, the majority of clinic personnel cited
transportation as the main barrier to gaining access to prenatal care. Although clinic
personnel recognized lack of transportation as a barrier, and more significantly, perceived
it as a significant fictor in patients' non-compliance — meaning that women did not
show up for their scheduled appointments — many clinic personnel felt that lack of

transportation was a poor excuse for missing appointments because their clinic offered

123

Figure 6.1
Socioeconomic Barriers to Gaining Access to Prenatal Care
N, number of responses = 28

Number of Responses

          

Fear of Fear Clrnlc Doesn't
. 1 Cultural Denial of None
~ Being w 1 A Understand
Trans ortItvon Len ue e on ccept Laz
p Recognized g g Medice' y the System Beliefs Pregnancy

free bus tokens and vouchers for taxi rides. Mindy, an Asian Registered Nurse at the
Public Health Clinic, articulated this position:

Lack of transportation —no car —is a main

barrier. Their house might be too far from

the bus or they might have car problems but

they can call for help — arrange rides via

the mother/infant outreach [program]. We

also have bus tokens and taxi vouchers for

them.

Recognizing that women might not know about the services available to them,

some clinic personnel considered not knowing how the "system" works to be a barrier to

gaining access to prenatal care. The "system" to which these clinic personnel referred

encompassed both the resources available through their clinics, such as bus tokens and

124

taxi vouchers, and Medicaid in general Jim, a physician, and Tanya, a fimily nurse
practitioner, both articulated this point:

There is a perception of rejection because of
Medicaid. Lots of clinics reject them
[women who use Medicaid] so they are
afiaid to call the doctor's oflice. As a result
they don’t brow what's available.

[Jim, Physician, Latino Community Center
Clinic]

Not everyone brows they can apply for
Medicaid . . . They think they are saving
money by waiting [to apply] and don ’t
realize how the system works — that it 's
more available for pregnant women.

[T anya, Family Nurse Practitioner, Public
Health Clinic]

When pressed to identify "barriers" that might be specific to low-income Mexican
American women's experiences, the majority of clinic personnel interviewed replied that
they could not think of any. Three clinic personnel did however, identify language as a
barrier. Two of the clinic personnel, a nurse and a physician, felt that Mexican
American, and Mexican, women who could not speak English were at a disadvantage
because they would not be able to understand the clinic staff or be able to follow
prescriptions. Lucinda, an intake worker at the Public Health Clinic who spoke Spanish
as her first language however, perceived not speaking English as a far more fundamental
barrier to gaining access to health care. In Lucinda's view:

Some patients are treated nicer than others.
If a Hispanic woman does not speak English
they [the fi'ont desk] get frustrated. One of
the women who works up there will turn
away and tell her to sit until her interpreter

arrives or reschedule her appointment
unless I can catch them.

125

Lucinda fiuther pointed out that as English speakers we take much for granted in terms of
getting through the application and appointment process. Lucinda thus considered
language to be a primary barrier ficed by low-income Mexican American women in
gaining access to health care.

Although only three clinic personnel identified barriers specific to Mexican
American women, discussion of ethnicity and cultural beliefs permeated the majority of
clinic personnel's explanations of how low-income Mexican American women gained
access to prenatal care. For example, health care found women's reliance upon friends
and family to be a major deterrent in women's access to Medicaid. As figure 6.2
illustrates, many clinic personnel realized that issues such as residency, language, social
stigmas, and the application process negatively influenced low-income Mexican
American women's access to Medicaid.

Figure 6.2

Barriers Specific to Low-income Mexican American Women
N, number of responses = 24

      

38%
Language

 
   
    

8%
Exist but
Couldn't identify

    

 
    
  
 

2196
Non-Resident

  

Transportation

  

 

‘——4%
Cultural
Beliefs

126

From clinic personnel's view, these barriersiwere fundamentally based, and in many ways
promoted, by the fimilies of their patients. For example, a non-resident who did not
speak English would not be able to rely upon her family, who were also non-residents
and non-English speakers, to help her ficilitate the process of applying for Medicaid. As
a result, she would not be able to complete the application forms and, more generally,
understand the Medicaid system as a whole. Pam, a registered nurse at the Latino
Community Center Clinic, expressed frustration with this scenario explaining that the
information low-income Mexican American families often do have is based on
conflicting stories about what services and resources are available through Medicaid.
Pam firrther explained that women, and their fimilies, who are legally in the United
States as non-residents often do not trust services or people they are not fimiliar with,
much less a government that they perceive as being suspicious and hostile towards them
Clinic personnel inclination to equate low socioeconomic status with belonging to
an ethnic minority was similarly articulated when I pressed clinic personnel for the
reason they thought low-income Mexican American women chose not to work when
pregnant. Clinic personnel responses encompassed educational, physical, motivational,
and cultural variables (see figure 6.3 below). A number of clinic personnel believed that
women did not work simply because they were lazy. Their responses were simple and
straightforward — "I don't know, they're lazy" [Angela, Reception Clerk, Hospital
Clinic]. When pressed further, clinic personnel such as Angela explained that women

used pregnancy as an excuse not to work because they are basically lazy.

127

 

Figure 6.3
Why Women Do Not Work During Pregnancy
N, number of responses = 26

 

19%

Job too
Phye’edly Demendno

 

new

Husband Doesn't
Want them to Work

In contrast, a number of clinic personnel believed that women's reasons for not
working while pregnant were based on cultural beliefs and their upbringing. A few clinic
personnel believed that Mexican American women perceived pregnancy as an illness. As
a result, it would only make sense that they would not work when "sick." Two Asian
clinic personnel, one a physician and the other a registered nurse, felt that Mexican 9
American women's cultural backgrounds played a significant role in not only women's
decision not to work but established behavioral expectations for women during their
pregnancy.

Cultural background in Mexican and
Korean people taught that women have to be

128

 

resting -— not to do anything. I can relate.
That is my cultural upbringing. [Jim,
physician, Latino Community Center Clinic]

Similarly, some clinic personnel believed that fimily perceptions of pregnancy
greatly influenced low-income Mexican American women's decision not to work.
Building upon the notion of cultural beliefs, clinic personnel who articulated this view
thought that a woman's upbringing framed a woman's expectations of her pregnancy. If a
mother did not work when she was pregnant than her daughter would not do so either.
Cory, a registered nurse at the Public Health Clinic, explained:

[A woman will] ask when she can stop.

Must perceive that working and pregnancy
do not go together after a certain point. [It
used to be that a ] teacher or nurse could not
show in pregnancy —— they had to quit when
they did. These are their parent 's attitudes .

. . . don ’t realize that it has changed —
pregnancy is normal.

Cultural Competency

While the low-income Mexican American interviewed in this study did not
articulate that ethnicity influenced their access to health care, ethnicity figured centrally
in clinic personnel perceptions of low-income Mexican American women's access to
prenatal care. As illustrated in the first half of this chapter, ethnicity shaped clinic
personnel perceptions of why women did not work during pregnancy and why they did
not have private health insurance. Ethnicity also shaped clinic personnel interactions
with low-income Mexican American women at the most fundamental level as well. If a
woman, or the person accompanying her to prenatal visits, did not speak English and

there was no one in the reception area who spoke Spanish then she was rescheduled for a

129

 

time when she could bring an interpreter — either a family member or friend that could
speak English or an interpreter fiom Refugee Services.

The ethnic basis of clinic personnel's explanations of low-income Mexican
American women's access to prenatal care is shaped by their understanding of what it
means to belong to an ethnic minority. In the following discussion, I argue that
provider's understanding of what it means to belong to an ethnic minority is premised
upon the conceptual framework of cultural competency. Based upon research that
assesses demographic and health status statistics for a given ethnic minority population in
relation to the role of culture in health care, cultural competency training has been
defined as "[t]he knowledge and interpersonal skills that allow clinic personnel to
understand, appreciate, and work with individuals from cultures other than their own It
involves an awareness and acceptance of cultural differences; self-awareness; knowledge
of the patient's culture; and adaptation of skills" (McManus, 1998).

The goal of cultural competency training classes has been to help clinic personnel
perceive their patients' cultural beliefs about health and illness as a positive tool in the
treatment process. The traditional venue of disseminating information about ethnic
minority populations however, in which portraits of ethnic minority groups are intended
to provide a general overview of demographic, socioeconomic, and cultural beliefs, has
permeated not only how clinic personnel's shape their interactions with minority patients
in the clinical setting but clinic personnel's expectations about their patients' everyday
experiences and behavior outside of the clinic as well. For example, Lucinda, an intake
worker at the Public Health Clinic, reasoned that low-income Mexican American women

did not have private health insurance because of: residency issues (as new immigrants

130

they would be unemployed), not having a job that ofiered medical benefits, not wanting
to hold a 9 to 5 job that would provide benefits, and because they were lazy — "It's sad to
say but they believe that welfare will take care of them if them if they don't work." She
further pointed out that the majority of low-income Mexican American women she saw
in the Public Health Clinic did not have much education, arguing that this is due to "the
way that they were raised." As she explained, Lucinda bracketed the latter phrase in ...

quotes because she believed that the parents of the women she saw in the clinic passed Q

 

their values on to their children. Consequently, Lucinda perceived laziness, not wanting l
to hold a 9 to 5 job, and little education as had little education themselves, as cultural

beliefs, or values, that shaped low-income Mexican American women's reliance upon

Medicaid and use of clinic services.

In learning to be culturally sensitive of the beliefs and practices their patients
adhere to, clinic personnel have been given a boilerplate of ethnic and cultural
characteristics upon which to flame their interactions. Instead of assessing a patient
based upon individual qualities, clinic personnel's frame their expectations and
interactions with patients upon generalized behaviors and beliefs of what it means to
belong to a particular ethnic or cultural group. Linda Hunt (1998) has similarly argued
this point in her assertion that physicians' explanations of illness and moral reasoning are
shaped in terms of generalized presumptions about how "groups" of people behave. In
this sense, I argue that efforts to help biomedical practitioners become culturally sensitive
to minority populations beliefs and perspectives have reified ethnicity. Diane, a

Reception Clerk at the Public Health Clinic, illustrated this point when asked if Mexican

131

American women on Medicaid are perceived or treated differently by health care
professionals than white or other ethnic women in Medicaid.

No, in fact the Asian women are so sweet.
We 've all had some kind of ethnic training.
Muslims are wondeflul — don 't mind
waiting, using an interpreter —— lots of
smiles. Hispanic women, now they used to
have their babies in the field The last
generation did not seek prenatal care unless “I
[there was] a problem. They had midwives
but that 's changing.

arr

 

The barriers ficing low-income Mexican Americans women's access to health
care lmve been similarly reified — just as "ethnicity" has been reified in the cultural
competency training of clinic personnel. Understandably, efforts to conceptualize the
overwhelming barriers inhibiting low-income women's access to health care necessitated
boiling the complexity of health care access down to a firndamental level in which
tangible solutions could be devised and implemented. The issues presented above and
throughout this entire document clearly indicate that clinic personnel are not only
conscious of these barriers but, more significantly, working to overcome many of the
barriers. For example, both women and clinic personnel in this study cited transportation
as a major barrier to women's access to prenatal care. In response to this barrier, all three
of the clinics in this study made bus tokens and taxi vouchers available to their clients.
Similarly, clinic personnel understood that despite being employed many of their clients
relied upon Medicaid because their employers either did not offer health benefits or
women could not afford to pay a premium for private health insurance.

I argue however, that despite recognizing and attempting to remedy these barriers,

gaining access to prenatal care is far more complex than the barriers lead clinic personnel

132

to believe. While it is understandable that complex barriers have been oversimplified in
an effort to implement manageable remedies, clinic personnel, and their organizations,
response to barriers inhibiting low-income Mexican American women's access to
prenatal care as been formatted upon the guise of the cultural competency framework.
The remedies clinics offer to help women gain access to care are conceived upon
portraits, or generalizations, of the barriers clinic personnel perceive women to be ficed ~-
witlr In essence, the remedies are formulated upon abstract notions that become fixed

perceptions of what it means to belong to an ethnic minority. As such, the reified barriers

 

equate with reified solutions that do not recognize the process women negotiate or the
social resources they manage to gain access to prenatal care. While bus tokens and taxi
vouchers are tangible, and manageable, remedies for a lack of transportation, they can not
begin to address the underlying dynamics that make transportation an issue in a low-
income woman's life to begin with.

Problematizing ethnicity in this manner ultimately does a great disservice to clinic
personnel's understanding of how low-income populations gain access to health services
for it reifies what it means to belong to an ethnic minority. As a result, clinic personnel
conclude that ethnicity, rather than women's social resource management, plays a more
significant role in shaping low-income Mexican American women's access to prenatal

care.

133

Chapter 7: Conclusions

Social Resource Management: Women's Stratggiee & Clinic Personnel's

Misconceptions

As low-income Mexican American women go through pregnancy and birth they
achieve access to prenatal care through a series of decision and routines that I have
analyzed as social resource management. The social resources that women draw upon in
the form of family, finds, and co-workers as social networks of information and
support, help them to address issues related to childcare, transportation, working both in
and outside of the home, and unemployment in gaining access to prenatal care. The
strategies that low-income Mexican American women develop in this process
consequently involve steps — alliance building — that they strategically manage based
upon the broad sc0pe of their social resources.

Drawing upon concepts fiom critical medical anthropology to analyze women's
social resource management I have shown that women make decisions and develop
strategies to gain access to prenatal care that are shaped by both political and economic
issues. For example, women in this study often relied upon a friend to drive them to their
prenatal appointments and expressed concern about the lengthy Medicaid enrollment
process. Transportation and payment for needed medical services, both fundamentally
economic and political issues, thus shaped the strategies that many women developed to
gain access to prenatal care. In this context, women's social resource management is not

a single logical construct that is closed and independent of other systems but rather one of

134

 

options in which women's strategies are shaped by social, economic, political, and
medical issues.

Clinic personnel's understanding of the elements involved in gaining access to
prenatal care did not encompass women's social resource management. While clinic
personnel identified socioeconomic issues, such as transportation, fick of health
insurance, and the inability to pay for needed medical care, that low-income women must '3'

overcome in achieving access to care, they viewed these issues as isolated events, or

 

barriers, rather than a series of interconnected issues that women addressed by drawing ‘
upon the social resources available to them. Perceived in isolation, clinic personnel

consequently concluded that barriers, such as the aforementioned, had been successfirlly

overcome once women attended a clinic appointment and enrolled in Medicaid.

Clinic personnel further contextualized socioeconomic barriers inhibiting low-
income Mexican American women's access to prenatal care in terms of ethnicity —
equating low income with belonging to an ethnic minority. As I have discussed, many
clinic personnel consequently viewed ethnicity as a primary fictor in shaping low-income
Mexican American women's access to prenatal care. For example, many clinic personnel
in this study believed that low-income Mexican American women chose not to work
while they were pregnant because they were lazy. Clinic personnel concluded that since
women were unemployed and pregnant they relied upon Medicaid and thus had access to
prenatal care. In such instances, clinic personnel characterized laziness as a Mexican
American trait and perceived laziness, rather than a socioeconomic issue, such choosing
to be a homemaker due to the high cost of childcare, as the reason why women were

unemployed and using Medicaid. Using the concept of ethnicity in this manner

135

ultimately does a great disservice to understanding how low-income populations gain
access to health care services for it reifies what it means to belong to an ethnic minority.
More significantly however, it illustrates that clinic personnel, and their organizations,
fail to understand the firndamental role social resource management plays in shaping low-
income, ethnic minorities access to care. In doing so clinic personnel fail to look beyond
the boundaries of their clinics, the Medicaid system, and ethnicity to understand, for

example, why some low-income Mexican American women might not work during

pregnancy.

Divegging Perspectives of Access

Examining low-income Mexican American women's social resource management
from the perspective of both the woman who is negotiating access to prenatal care and
the clinic personnel giving care illuminates the divergence of their perspectives on
gaining access to care. In the most firndamental sense, many clinic personnel in this
study could not begin to conceptualize the integral role social resource management
played in low-income women's strategies to gain access to care. Clinic personnel's
references to "one-stop-shopping" of services offered at their clinics, as Diane, a
Reception Clerk at the Public Health Clinic, made (Chapter 5), unwittingly
acknowledged the role social resource management plays in developing a strategy to gain
access to care. This statement indicates that clinic personnel recognized that for an
individual to travel fi'om a physician's office, to a laboratory, and then to a pharmacy

depended upon the resources, such as a car or bus, a person had access to. Despite this,

136

 

clinic personnel were unable to conceptualize how having access to social resources in
turn promotes or limits a woman's access to prenatal care.

The concept of "one-stop-shopping" is indicative of a second divergence between
women and health are clinic personnel's understanding of gaining access to prenatal care.
While clinic personnel identified socioeconomic issues, such as transportation problems,
that women were faced with in gaining access to prenatal care, they often conceptualized
transportation problems as isolated issues or barriers rather than viewing them in a series
of interconnected events that women addressed through the social and economic
resources available to them. "One-stop—shopping," where many services were provided
by the clinic, was thus seen as remedy to this barrier. I believe that this distinction is
significant for it addresses a fundamental premise of clinic personnel's conceptualization
and use of the term "barrier." Clinic personnel perceived barriers inhibiting low-income
Mexican American women's access to prenatal care in terms of their contact with a
physician or prenatal clinic. They presumed that despite any possible barriers that might
exist, access to prenatal care was a given since their organizations — clinics — provided
a variety of services and resources that they perceived as being readily available to
women.

Ethnicity also figured centrally in clinic personnel's understanding of "barriers,"
and, consequently, their perceptions of low-income Mexican American women's access
to prenatal care. As I have previously discussed, ethnicity shaped clinic personnel's
perceptions of why women did not work during pregnancy and why they did not have
private health insurance. Ethnicity also shaped clinic personnel interactions with low-

income Mexican American women in the clinical setting as well. In light of this, I argue

137

 

that the ethnic basis of clinic personnel's explanations of low-income Mexican American
women's access to prenatal care is shaped by their understanding of what it means to
belong to an ethnic minority. I firrther posit that clinic personnel's understanding of what
it means to belong to an ethnic minority is premised upon the conceptual framework of
cultural competency. In learning to be culturally sensitive to the beliefs and practices
their patients adhere to, clinic personnel have been given a boilerplate of ethnic and
cultural characteristics upon which to frame their interactions. Instead of assessing a
patient based upon individual qualities, clinic personnel frame their expectations and
interactions with patients upon generalized behaviors and beliefs of what it means to
belong to a particular ethnic or cultural group. As a result, cultural competency training
has led clinic personnel to reify ethnicity. The barriers ficing low-income Mexican
Americans women's access to health care have been similarly reified — just as
"ethnicity" has been reified in the cultural competency training of clinic personnel.
Remedies clinics offer to help women gain access to care, such as bus tokens or taxi
vouchers, are conceived upon portraits, or generalizations, of the barriers clinic personnel
perceive women to be ficed with. The reified barriers equate with reified solutions that
do not recognize the process women negotiate or the social resources they manage to gain
access to prenatal care. Problematizing ethnicity in this manner ultimately does a great
disservice to clinic personnel's understanding of how low-income populations gain access
to health services for it reifies what it means to belong to an ethnic minority. As a result,
clinic personnel conclude that ethnicity, rather than women's social resource
management, plays a more significant role in shaping low-income Mexican American

women's access to prenatal care.

138

 

A final divergence between women and health care provider's perspectives of
health care access is the actual locus of "access." As I have discussed, clinic personnel
perceived the locus of access as centered within the clinic itself whereas women placed it
outside of the clinic — as something that precedes the clinic. For many women
strategizing ways to gain access to prenatal care this meant juggling a husband's
expectations about their role as a wife and mother with the cost of health insurance
premiums, lack of transportation, limited work related networks, and dependence upon
familial networks. For others it meant working in a job that did not offer health insurance
benefits, relying upon parents for advice about prenatal care and Medicaid.

In contrast, many clinic personnel in this study firmly perceived "access" as
action within the realm of Medicaid and, more specifically, the clinic. While some clinic
personnel recognized the link between enrolling in Medicaid and gaining access to a
clinic, they perceived "access" as a clinical issue grounded in quality of care. In doing so
they asserted that once women were in the clinic they received "wonderful" care ——
meaning that they have access to physicians, ultrasounds, nutritionists, social workers,
and the laboratory.

By drawing on concepts fi'om critical medical anthropology to analyze low-
income Mexican American women's access to prenatal care during pregnancy and birth,
my goal has been to portray a picture of how women consciously negotiate a decision
making process grounded in social resource management. The strategies that women
develop to gain access to prenatal care involve steps that they manage based upon the
broad scope of their social resources. I define social resource management as a process

in which women draw upon their social networks — in the form of kin-based, friend-

139

 

based and work-related networks — to address issues of childcare, transportation,
working both in and outside of the home, and unemployment in ficilitating access to
prenatal care. While each of these networks were largely separate, women in this study
configured their use of the networks differently. For example, one woman might rely
primarily upon her fimily-based network for information about prenatal clinics and to
meet her transportation needs whereas another woman might rely upon her friend-based
network for information about prenatal clinics and upon her work-related network for
transportation. Some women might have only had one network to draw upon whereas
another could rely upon all three of the networks. As such, women's social resource
management is not a single logical construct that is closed and independent of other
systems but rather one of options in which women's strategies are shaped by social,
economic, political, and medical issues.

In examining the views of women and clinic personnel as actors and strategists
actively navigating a health care system I have addressed some of the disparities between
low-income Mexican American women's and clinic personnel's views of gaining access
to prenatal care. Most significantly, women's perception of "access" as a process that
preceded and eventually led to a clinical encounter, in contrast to clinic personnel's
conceptualization of "access" as an action bounded by the clinic. Recognizing the
dichotomy between women's and clinic personnel's conceptualizations of wlfit is
involved in achieving access to prenatal care sheds new light on the process of gaining
access to care. The disparity between women's and clinic personnel's views of access to
prenatal care have distinct implications for the ways in which clinic personnel and policy

makers attempt to remedy the barriers low-income women belonging to an ethnic

140

 

minority are ficed with in managing access to prenatal care. These solutions in turn,
directly impact the ways in which low-income Mexican American women manage social

resources to gain access to care.

141

“W”!

APPENDICES

142

 

Appendix A: Interview Guide — Women Seeking Care

Name

Age

Ethnicity

Marital status

Current residence

Born where

Considers to be from
Education

Employed (8)

Spouse/partner employed (5)
Do you combine your income?
Other additional income (from people/organizations)
Number of children

Pregnancy number

Weeks pregnant

Extended fimily

Parents from

Grand parents from

Number of siblings

Where do the above live

What kind of work do they do?
Who do you live with?

Current Pregnancy
Health insurance

Prenatal care

When started

Found out about how
Found out about clinic how
Chose physician how
Transportation to clinic
Other services used

Found out about these services how
Plans to give birth where
Problems with pregnancy
Relationship with physician/ nurse practitioner
Relationship with clinic staff (nurses, receptionists etc.)
Problems using the clinic
Clinic you wanted to use but couldn't
Services you wanted to use but couldn't

143

 

Previous Remy
* If applicable ask questions listed above.
Is this pregnancy different from your previous one(s)? How?

Birth Plan/Expgriences
Describe birth plan
Deliver where
Get there how
Who will be there with you?
Who will watch your children?
Do you think this birth/delivery will be different or the same as the previous one(s)?
How?

144

 

Appendix B: Interview Guide — Clinic Personnel

Name

Age

Ethnicity

Marital Status

Born where
Considers to be from
Education

Children

Prenatal care
Welfare/Medicaid
Occupation/yrs.
Organization/yrs.
How profession was chosen

 

Women's reasons for obtaining prenatal care (why they think they need it)
How do women find out about prenatal care?

How do women find out about a clinic?

How do women choose a clinic?

Are there barriers to finding out about prenatal care?

Are there barriers to using prenatal care?

Are there barriers to using this clinic?

How do women find out about Medicaid?

Are there barriers to gaining access to Medicaid?

Does Medicaid provide enough coverage?

Do women on Medicaid receive different care from women with private insurance?

Are women who use Medicaid perceived or treated differently by medical staff than
women with private insurance?

Problems with the Medicaid system?

Are there barriers specific to Mexican American women in gaining access to prenatal
care?

Are there barriers specific to Mexican American women in gaining access to your clinic?

Are there barriers specific to Mexican American women in gaining access to Medicaid?

Does ethnicity play a role in the provider/patient relationship?

Does your ethnicity influence your relationship (positively or negatively) with patients?

145

Are Mexican American women on Medicaid perceived or treated differently by medical
staff than "white" (or other ethnic) women on Medicaid?

Mexican American women might not work while pregnant because?

Mexican American women might not have private health insurance because?

 

146

Prenatal Care

Appendix C: Aggregate Data from Interviews with Women Seeking

 

 

 

 

 

 

 

 

 

 

 

Part I
A. Location of Interview Number of Interviews
Latino Community 8
Center Clinic
Public Health Clinic 7
Hospital Clinic 12
Total 27
B. Average Age 23 Standard Deviation = 3.9
Sample Range = 18-36
C. Marital Status
Single 15
Married 11
Divorced 1
Widowed 0
D. Born in:
Lansing 13
Greater Lansing Area 3
Southwestern United 4
States
Mexico 7
E. Current Residence:
Lansing 21
Greater Lansing Area 6
F. Considers herself
From:
Lansing 13
Greater Lansing Area 3
Texas 3
California 2
Mexico 6

147

 

 

G. Education:

Completed 6Th Grade

Completed 8"1 Grade

Completed 9th Grade

Completed 10th Grade

Completed 11‘” Grade

Graduated from High
School

Completed GED

Attending Community
College

Graduated from College 1

Attending Nursing School

Unknown 4

 

wk Lumen—....

_

 

H. Occupation:
Homemaker
Food service
Cashier
Retail
Childcare
Security Officer
Maintenance/Housekeeping
Student

 

NNl-‘Nl-‘NOOG

 

I. Women's Work Activities in

Pregnancy

Employed Outside the 8
Home

Unemployed

Homemaker 6

Not Working because of
Baby's Health

In School

Not Working because of
Childcare &
Transportation Problems

Not Working because 2
Husband is Against it

w

l-‘NO

148

 

Plans to Return to Work after
Birth of Baby:

 

Yes
N0

N0

 

Partner's Occupation:
Food Service
Construction
Computer Technician
Cableman

Artist

Gas Station Attendant
Machinist
Unemployed
Unknown

No Partner

@ww—‘I—‘U—‘i—Ie—OAQ

 

Do you and your partner
combine your income?

 

Yes
No

17

 

Additional income from
government programs:

 

WIC

Food Stamps
Welfare
None

10

_

 

Additional income from
family members:
Parent/Guardian

Child Support from Ex
None

N

 

Average Number of Children

1.2

149

Standard Deviation = 0.7
Sample Range = 0-4

 

 

Average Number of 2.4 Standard Deviation = 1.0
Pregnancies Sample Range = 1-6

 

Number of Weeks Pregnant
(Median) 28 Sample Range = 12-40

 

Other Relatives in the Area:

 

Parent/Guardian
Siblings
Aunt/Uncle
Cousins
Grandparents
None

\rooinba‘a

 

Household Includes:

 

Parent/Guardian 4
Husband/Partner 14
Children 1 0
Roommate 1
Sibling 4
Alone 1

 

Health Insurance for Current

 

Pregnancy:

Applying for Medicaid 5

Medicaid 18
Private Insurance 1

None

 

Health Insurance with
Previous Pregnancy:

 

Medicaid 13

Private Insurance

Used Health System in 1
Mexico

None 1

 

150

 

Part II

A. Found out About Prenatal
Care F ronr
Mother
Always Known About It
Doctor
A "Free Clinic"
A Sibling
Other Family Members
Friends
School
Books
Can't Remember

 

QHUI-hG-‘r-‘Ni—‘05

 

B. Reason for Obtaining Prenatal

Care:

Find out problems with the 3
pregnancy.

To make sure nothing l4
happens to the baby.

Important to be checked by a
doctor.

Get vitamins.

Needed when pregnant.

Good for the mother's health.

Not sure.

 

N

\INWM

 

C. Found Out About the Clinic

From:

Information handed out at a 6
clinic.

Information handed out at the 3
hospital.

Always known about it.

Had used the clinic previously 4
or knew someone who
worked there.

Family

Friends

School

Other

Not sure

LN

Nr-‘F-‘QOO

151

 

 

 

 

D. Chose Physician Based Upon:

 

Friends' recommendation 1
Discussion with nurse 2
Assigned by clinic 20
Chose from a list 3
Not sure who is their doctor 1

 

E. Transportation to the Clinic:
Owns a car
Partner
Parent/Guardian
Friend
Relative
Bus
Bike
Walk

 

HHANNNQ;

 

F. Found Out About Prenatal
Care From:
Partner
Family
Friends
Clinic
County Health Department
Not Sure

 

NWhWN—t

 

G. Problems you've had using
the clinic:
Always see a different
provider. 3
Not in one place long enough
to use the same clinic. 4
No problems but would use
different clinic if had 2
private insurance.
Don't have a phone to call the
clinic. 2
Don't understand the
Medicaid paperwork. 4
Period for enrolling in
Medicaid too 10% 4

 

152

Appendix D: Aggregate Data from Interviews with Clinic Personnel

 

 

 

Part I
A. Location of Interview: Number of Interviews:
Latino Community 5
Center Clinic
Public Health Clinic 5
Hospital Clinic 5
Total 15
B. Average Age 43 Standard Deviation = 12.0

Sample Range = 21-59

 

C. Ethnicity (assigned by
interviewee):
Asian
Caucasian
Hispanic
Irish/Polish
Korean American
Mexican American
Norwegian
Swedish/Finnish
White
White American
White/Polish

 

r—ei—IAu—Ir—Oi—nu—er—oNr—ei—I

 

D. Marital Status
Single
Married
Divorced
Widowed

 

—-O\O\N

153

 

 

Born in:

 

Lansing

Greater Lansing Area

Upper Peninsula of Michigan
Midwestern United States
Southwestern United States
Korea

Taiwan

r—el—eNr—eu—smb

 

Education:

Completed High School

Completed GED

1 Year Associate's Course

Associate's Degree

2 Year College/Nursing
School

Military Medical Training

Bachelor's Degree

Master's Degree

Medical Degree

 

g—ewg—eg—a

wen—u.

 

Average Number of Children 2.1 Standard Deviation = 0.7
. Sample Range = 0-4

 

Did you, or your partner,
receive prenatal care when
pregnant?
Yes 13
No 0

 

Have you ever used
Medicaid?

 

Yes 5
No 1 0

154

 

J . Occgration:
Reception Clerk
Clinic Nurse
Nurse Practitioner
Physician
Clinic Coordinator

i—ee—di—Iqm

 

K. Average Number Years of
Experience: 15.4 Standard Deviation = 7.4
Sample Range = 2-30

 

L. Average Number of Years
with Organization: 7.3 Standard Deviation = 6.9

Sample Rage = 08-21

 

Part II

A. WhLWomen Obtain Prenatal Care:
Health of the Baby
Find Out Sex of the Baby (Ultrasound)
The "Right" Thing to Do
Fears about Pregnancy
To Establish a Connection with a

Hospital

Mother's Health 1

 

«k—‘N-‘O

 

B. How Women Find Out About Prenatal
Care:
Friends
Mother
Other Family Members
By Word of Mouth
Clinic Where Pregnancy Test was
Done
Common Knowledge
School Programs
Husband/Partner

 

WNGUIOO

u—IUJN

 

155

 

C. How Women Find Out About/Choose a

Clinic:

 

Friends

Mother

Other Family Members
Health Department

Other Clinics

Used the Clinic Previously
Word of Mouth

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eamewwo

 

Basis of Women's Choice of Clinic:

 

Know the Clinic is Free
Don't Want Parents to Know
Location

Health Department

Not Sure

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Barriers to Using Prenatal Care:

 

Transportation

Fear of Being Recognized by Friends
or Relatives

Language

Fear that a Clinic Won't Accept
Medicaid

Lazy

Doesn't Understand the System

Cultural Beliefs

Denial of Pregnancy

None

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ww—t-C-N

 

How Women Find Out About
Medicaid:

 

Friends

Mother

Other Family Members

Clinic Information

Word of Mouth

Common Knowledge

Through Use of Other Services
Advertisements

Health Department

"Inside Contact"

156

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G. Barriers to Garnm Access to Medicaid:

 

Non-resident

Language/Illiterate

Cultural Beliefs

Associated Stigma

Doesn't Understand the Application Process
Make Too Much Money to Qualify

Know They Exist but Couldn't Identify Any
None

NNr-‘UtUJ—‘h-h

 

Quality of Coverage —-— Medicaid vs. Private
Health Insurance:

 

No Difference

Medicaid Provides Better Coverage

Private Health Insurance Provides Better
Coverage

Not Sure

more»

 

Are Women on Medicaid Perceived or
Treated Differently than Women with
Private Health Insurance:

 

Yes
No
Maybe

GOO

.5

 

Barriers Specific to Low-income Mexican
American Women Gaining Access to
Prenatal Care:

 

Language

Transportation

Cultural Beliefs
Non-resident

Exist bust Couldn't Identify
None

157

MNUIr-‘NO

 

 

 

K. Role of Ethnicity in the Provider/Patient

Relationship:

 

Language Problems

Clinic Personnel Might have Problems with
Patients

Patients Might have Problems with Clinic
Personnel

Culture Clash

Ethnicity Influences the Relationship but
Not Sure How

No

Au-e

 

Influence of Clinic Personnel's Ethnicity
on their Relationship with Patients:

 

No Influence
Positive Influence
Negative Influence

W-bOO

 

Mexican American Women using
Medicaid Perceived or Treated Differently
by Clinic Personnel than Others on
Medicaid:

 

Yes

Depends on the Person
Maybe

No

OOH-RN

 

Mexican American Women Do Not Work
While they are Pregnant Because:

 

Lazy

Depend on Welfare

Do Not Have Enough Education
Husband Doesn't Want them to Work
Job too Physically Demanding
Cultural Beliefs

Didn't Know

158

AONUt—‘F-‘WO’t

 

 

0. Mexican American Women Do Not Have
Private Health Insurance Because:
They're Not Working
Depend on Welfare
Not Enough Education
Job Does Ofier it/Can't Afford it
Required Waiting Period at Job
Not Married

159

Nd

~

10

_

 

 

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