Health care system barriers and facilitators to early prenatal care among diverse women in Florida

Abstract

Background Worldwide, women continue to experience barriers to accessing early prenatal care. Given the unique nature of the United States health care system, this study aimed to identify barriers and facilitators to early prenatal care reported by women in Florida. Methods A mixed‐methods study of postpartum women with entry to care after 14 weeks’ gestation was conducted at a tertiary care hospital in Florida. First, eligible women completed a survey including demographic characteristics and open‐ended questions on prenatal care barriers. Second, a semi‐structured interview was conducted to contextualize the conditions of access. The qualitative analysis was based on the combined theoretical frameworks of Phillippi and Khan. Results The majority of the 55 participants self‐identified as Hispanic (n = 28, 51%), non‐Hispanic White (n = 12, 22%), or non‐Hispanic Black (n = 9, 16%). Quantitative analysis identified frequent barriers, including the following: “couldn't get an appointment when wanted one” (n = 24, 47%); “didn't have insurance” (n = 21, 41%); and “not aware of pregnancy” (n = 21, 41%). From the combined quantitative and qualitative analyses, three major themes emerged that help to explain barriers faced by birthing people in Florida: personal factors (mental health, awareness of pregnancy, considering abortion, tumultuous life), community conditions (transportation, stigma/fear, social support), and health care system (language barriers, delay at clinic level, cost of care). Discussion Barriers to early prenatal care are multifaceted and operate at personal, societal, and health care systems levels. Prenatal care practitioners have multiple potential targets for interventions at the clinic level to help mitigate barriers to early prenatal care. Strategies should include health care policy reforms to Medicaid access and interventions at the clinic level aimed at fast‐tracking access to care.

A systematic review of the qualitative literature on barriers to high‐quality prenatal and postpartum care among low‐income women

“…In addition, some prenatal care providers limit the number of Medicaid‐insured patients they accept, as Medicaid reimbursement for a standard prenatal visit is lower than private insurance reimbursement and requires a larger administrative burden 55 . Study participants described calling multiple providers to find one that would accept Medicaid insurance and waiting weeks for an appointment time 26,27,43 . Often, these barriers overlapped with personal delays in care seeking, such as the late discovery of pregnancy or homelessness 32 .…”

“…Transportation 22,23,27,28,30–32,34,36,41–44 and childcare issues 22,27,28,34,38,44 were also a challenge for many low‐income women. Some clinics and Medicaid programs offered free transportation to appointments.…”

“…If I would've known before, I would have definitely [sought prenatal care at] an earlier stage in the pregnancy" 27 Considering abortion 27,29,31 "I did not want to have her, until it got to the point that I had no other choice. I was too late by then" 29 Shame and stigma surrounding with pregnancy 22,[24][25][26][27]30,32 "…it was all surrounding my shame and embarrassment, and that's what was the driving force of me not seeking prenatal care from the beginning is mostly my insecurities, my guilt and shame that I still feel from my past bad decisions, bad choices. So I did not seek prenataland honestly I tried to ignore that this whole thing was even happening, which you can only do for so long.…”

“…So I was switching from doctor to doctor." 30 Challenges with provider continuity and poor inter-provider communication 23,26,27,31,33,35,39,42,47,49,50 "My problem was that I had three or four different doctors, and none of them talked to each other, as far as I could tell. So they would contradict each other to me in terms of when I could, leave in terms of when I'd get a particular test."…”

“…55 Study participants described calling multiple providers to find one that would accept Medicaid insurance and waiting weeks for an appointment time. 26,27,43 Often, these barriers overlapped with personal delays in care seeking, such as the late discovery of pregnancy or homelessness. 32 Participants also described being cut off from Medicaid insurance suddenly at 2 months postpartum and fearing bills for postpartum care.…”