Barriers to PNC and Designing Future Interventions
This study showed that most women faced several health system barriers when accessing PNC, and for some of these women, this resulted in delayed initiation of PNC and fewer PNC visits. The average participant in our study reported between two and three barriers to PNC, and this did not differ significantly by race, ethnicity, education, or income. Commonly reported barriers included difficulty scheduling visits, inability to leave work or school, and long wait times at the clinic. Having too many PNC visits was a more common barrier to care for non-Hispanic White women and women that identified as other racial and ethnic groups (including women that identified as Asian, American Indian, Pacific Islander, or two or more races) than for non-Hispanic Black and Hispanic women. While the other listed barriers to PNC were experienced by a similar percentage of women with different educational backgrounds, incomes, and racial/ethnic identities, this difference highlights the need for community input for tailored interventions to increase access to PNC.
Engaging patients, caregivers, and key stakeholders when designing interventions is vital to creating successful interventions [25–26]. For example, one study reported a 44% increase in patients starting PNC in the first trimester after redesigning operational and clinical processes, extending hours of operation, and increasing patient education and outreach. The authors report that the success of the intervention was in large part due to the engagement of patients and key stakeholders through surveys, focus groups, and graded feedback [27]. Other studies also show that patient and community engagement in research improves patient satisfaction with their care, community healthcare knowledge, participation in the intervention, and overall success [25–26]. This study population indicated that having ultrasound visits fall on the same day as obstetric visits and having some telehealth visits would improve their overall PNC attendance. Thus, this study begins to elicit the key health system barriers impacting access to care and potential interventions to improve access, but future qualitative research needs to be done to further engage the community and better define these barriers.
Disparities in Access to PNC and the Clinical Implications
This study also revealed notable variability of the gestational age at the initiation of PNC, based on race and ethnicity, educational attainment, and income. Hispanic women, on average, initiated PNC three weeks later than non-Hispanic White women (13 weeks and 6 days vs. 10 weeks and 5 days). Women who had completed some or all high school initiated PNC approximately five weeks later than those with a bachelor's degree or higher. Individuals with an annual income below $45,000 initiated PNC more than four weeks later than those with an income exceeding $140,000. These findings highlight those individuals identifying as ethnic minorities, possessing lower educational achievements, and having limited incomes tend to initiate PNC at later stages. Although these discrepancies are not linked to the self-reported barriers to PNC that were surveyed, the data remains significant and might reflect psychosocial and environmental obstacles influencing access to PNC.
These findings have several implications for patients and clinicians. Delayed initiation of PNC is a known predictor of adverse maternal and fetal outcomes. Early PNC facilitates the identification of life-threatening pregnancy complications, allows for risk reduction, and provides an opportunity to give early social support to pregnant persons. Late presentation and poor adherence to PNC are associated with adverse maternal behaviors, increased rates of maternal mortality, and low birth weight [8, 25, 28–30].
Further, complications such as a missed abortion, molar pregnancy, or ectopic pregnancy may be identified at early PNC visits, facilitating prompt treatment, and reducing morbidity and mortality. Delayed screening and management may result in increasingly invasive or unsuccessful measures to treat underlying pathologies. While our study was not powered to assess the effect of delayed PNC on pregnancy outcomes, other studies show late PNC results in poor maternal and fetal outcomes. Thus, these data may suggest that underserved communities and women of color have a disproportionally high risk of adverse pregnancy outcomes.
Disparities in adverse pregnancy outcomes and access to PNC are multifactorial and deeply intertwined with social determinants of health. Factors such as education, income, neighborhood safety, food security, chronic stress, racism, and discrimination impact overall maternal health and participation in PNC services [31–32]. One study found that education status was the strongest predictor of maternal mortality. This same study showed that racial disparities persist across all education levels, highlighting the complexities of risk factors for adverse pregnancy outcomes [31]. Researchers emphasized that the experience of racism and segregation, rather than maternal race itself, is the key factor that influences health outcomes. Distrust of the health system based on historical and contemporary discrimination often manifests as inequities in maternal health, decreased prenatal care utilization, and decreased adherence with treatment plans [33]. Additional research suggests that racial disparities in adverse pregnancy outcomes are the consequences of systemic racism leading to de-investment in non-White neighborhoods and differences in access to legal systems, education, jobs, and healthcare services. This leads to chronic disempowerment, depression, and subsequent disengagement with health systems and the underutilization of PNC. This study focused on nine specific health system barriers and thus did not fully explore how race, racism, and social determinants of health impacted access to PNC. We likely found no association between the number of barriers to PNC and late initiation of PNC because we did not study these other factors.
Moreover, women of color and those with low SES are more likely to have inadequate access to PNC and late initiation of PNC which ultimately increases the risk for poor maternal and fetal outcomes. The etiology of inadequate access to care and late initiation of PNC is complex and multifactorial. This study examined a limited subset of health system barriers that may be important in improving access to PNC. However, future research needs to better define these barriers and their interactions with systemic racism, psychosocial barriers to PNC, financial barriers to PNC, and more.
Limitations
Our study has limitations. It involved only 194 participants, limiting subgroup analysis and power to detect rare pregnancy complications. Generalizability might be constrained due to the small sample size. Conducted at Loyola University Medical Center, predominately serving low-income groups, findings may not extend to all regional women. Some participants did not share income and education data, hampering exploration of socioeconomic and racial disparities in PNC access. Survey responses could be biased based on postpartum recall. The study’s scope of barriers was also limited. The survey assessed a select set of health system barriers, chosen to gain insight into barriers that may be addressed by the healthcare team. However, most patients faced multiple, interacting barriers to PNC. Thus, additional qualitative data is needed to better understand the interaction of barriers that limit access to PNC. Importantly, the study excluded pregnant individuals without prior PNC to cous on enhancing institutional PNC. However, this hinders insights into high-risk cases, given that lacking PNC is associated with increased risk of preterm delivery and mortality [34]. Future studies should include this group community-wide improvements to care.