 |
|
Family Dysfunction and Native American Women Who Do Not Seek Prenatal Care
Hugh Tyson, MD;
Rosemary D. Higgins, MD;
Ingrid Tyson, FNP
Arch Fam Med. 1999;8:111-117.
ABSTRACT
| |
Objective To test the hypotheses that, in a health system with few external barriers to care, women with no prenatal care (NPC) have higher rates of nuclear family dysfunction and disproportionate amounts of adverse neonatal outcomes compared with women with prenatal care.
Design Case-control study.
Setting Indian Health Service system.
Patients Nuclear families of women not seeking prenatal care compared with those who did seek prenatal care.
Main Outcome Measures Dysfunctional outcome measures in nuclear families were children adopted, placed, or under protective surveillance; mothers denying pregnancy, being abused, or attempting suicide; and parents with alcoholism. Neonatal outcome measures were low birth weight and neonatal intensive care days.
Results Dysfunctional markers occurred significantly more frequently in families of women with NPC than in families of women with prenatal care (57% of NPC and 12% of control families; McNemar odds ratio, 14; 95% confidence interval, 4.7-41.6). Neonatal outcome in this Native American population showed that women with NPC had only 2.6% (58/2222) of the total births but accounted for 11% of the low-birth-weight infants (<2500 g), 18% of the very-low-birth-weight infants (<1500 g), and 24% of the level II and 41% of the level III newborn intensive care days.
Conclusions Women not seeking prenatal care in a system with few external barriers to care have significantly more family dysfunction (P<.001) than women seeking prenatal care. Infants of women with NPC generated a disproportionate amount of adverse neonatal outcome. The combination of NPC and family dysfunction was more predictive of adverse neonatal outcome than was NPC alone.
INTRODUCTION
STUDIES OF birth outcomes of women who do not receive prenatal care have shown increased rates of prematurity and low birth weight (LBW) compared with women receiving prenatal care.1-8 In addition, the LBW newborns of women with no prenatal care (NPC) have shorter gestations, higher complication rates, and more newborn intensive care (NBIC) admissions than do those of women with prenatal care.3-4,9 This in turn leads to increases in neonatal morbidity, mortality, and cost for LBW newborns of these women.3-4
Demographically, women with NPC are significantly more often unmarried, poor, less educated, from minorities, and without medical coverage than women with prenatal care.2, 4, 7, 9 Women with NPC have more substance abuse, higher fertility rates, more denial and negative attitudes toward their pregnancies and health providers, less valuation of prenatal care, and less favorable initial parenting practices than women who receive prenatal care.2, 9-11 Furthermore, they tend to have repeated pregnancies without prenatal care.2, 8, 12
Those studies have drawn their subjects with NPC from the mothers of infants in NBIC units and high-risk, urban obstetric populations with relatively high rates of NPC pregnancies.2-12 In those settings, the 2 most commonly identified external barriers to prenatal care, insufficient finances (medical coverage) and transportation, were either prevalent, partially specified, or unknown.2-12 This made it difficult to determine if the predominant reasons that these women did not seek prenatal care were external barriers to care, or if internal barriers (behavioral factors) also played a significant role.2 At least 2 studies have suggested that internal barriers, such as depression and denial, would prevent some women from seeking any prenatal care even if all external barriers to care were removed.2, 12-13 Other cited internal barriers to care include attitude, knowledge deficits, fear, and fatigue.14 Lack of psychosocial support has also been implicated as a barrier to prenatal care.15 Finally, 2 recent studies16-17 indicate that barriers to prenatal care exist at both the individual and the family level.
The purpose of this study was to explore the relationship between family dysfunction and the absence of prenatal care in a population with minimal financial and transportation barriers to medical care. We also sought to determine whether dysfunctional markers were significantly more common in the families of women with NPC compared with families of women who received prenatal care in a health system with diverse sources of social information (medical records, child protection registries, and community-based nurses). Finally, we investigated the hypothesis that women with both NPC and family dysfunction would account for most of the adverse neonatal outcome generated by all NPC births.
We reviewed the overall neonatal outcome during a 6-year period in a Native American population that received care from a community-based, federally funded, Indian Health Service (IHS) system in New Mexico. We examined the proportion of adverse neonatal outcomes caused by all NPC births and by the subset of births associated with both NPC and family dysfunction. We then compared the nuclear families of mothers with NPC with the nuclear families of matched controls who received prenatal care with regard to 6 dysfunctional markers (children placed or adopted out of the family, children under protective surveillance, physical abuse of the mother, pathological denial of pregnancy, maternal suicide attempts, and parental alcoholism) and other risk factors for LBW from the 1985 Institute of Medicine report.1
SUBJECTS AND METHODS
SANTA FE SERVICE UNIT POPULATION
The Santa Fe Service Unit (SFSU) is a level II, IHS health system providing care to 12 tribes of Native Americans in New Mexico. The SFSU has a central hospital in Santa Fe and 8 outlying clinics providing community-based care. The SFSU offers free prenatal and perinatal care to all women eligible for IHS medical services. The population of patients is approximately 17,000. Approximately 75% of the population served by the SFSU live within walking distance ( 1.6 km) of their local rural clinics.
Generally, first prenatal care visits in the SFSU are scheduled within 10 days of an initial pregnancy screening visit. Level II obstetrical and pediatric services are available at Santa Fe Indian Hospital (SFIH). Level III maternal and neonatal transports are sent to University of New Mexico Hospitals in Albuquerque.
MATERNAL POPULATION AND SOURCES OF DATA
All deliveries to women receiving IHS care and referred to or living in the SFSU from January 1, 1980, through December 31, 1985, were included in the study. This included births at SFIH; clinic, vehicular, and home births; births at hospitals en route to SFIH; and births from level III maternal transports. Level III maternal and neonatal transports from SFIH were recorded in the obstetric and neonatal logs. Information on the birth outcome and the hospital course of the mother and neonate was obtained from the level III facility. Data on clinic and non-SFIH deliveries were obtained from the delivering facility. Home births were usually transferred to SFIH. If they were not, birth information was obtained from the facility where the mother and newborn first received care. All data on the outcome of SFIH deliveries were obtained from obstetric and neonatal logs and maternal and neonatal charts. Prenatal demographic and neonatal outcome data for New Mexico and the United States were aggregated for 1980 through 1985 from statistical reports of the state of New Mexico health department and US Department of Health and Human Services.18-19 Population income data were obtained from the 1980 US census.20
SELECTION OF CASES AND CONTROLS
A case was defined as a pregnancy with NPC and having no record of any prenatal visits for that pregnancy in either the woman's hospital or local clinic chart. A matched control was a pregnancy selected by means of the following 3 criteria: (1) 1 or more prenatal visits for that pregnancy in the woman's hospital or clinic chart; (2) the woman associated with that pregnancy had to be from the same tribe as the case; and (3) the woman associated with that pregnancy had to be in the same age group as the woman of the NPC case. The age groups for matching were less than 20, 20-24, 25-29, and 30 or more years. Among women who satisfied these 3 criteria, the woman who delivered closest to the date of delivery of the index NPC case was then selected as the matched control. Tribal matching was done on the premise that tribes might differ in prevalences of dysfunctional markers. If a woman had more than 1 NPC delivery during the study period, she was considered a separate case for each NPC pregnancy; each of her NPC pregnancies was matched with a different control pregnancy. The term index is linked with a discrete NPC case or control and includes the pregnancy, newborn, and nuclear family for that delivery. Nuclear family was defined as the mother, father, and newborn of the index pregnancy and any children living in the home of that mother and under her care.
DYSFUNCTIONAL MARKERS
Dysfunctional markers were assessed according to the following definitions in the nuclear families of cases and controls.
Children adopted or placed out of the nuclear family: The voluntary adoption or a placement by tribal court order of children out of the nuclear family was documented on the maternal chart and/or reported by the community health nurse.
Children under protective surveillance: Child abuse registries were kept for all the SFSU tribes during the years of the study. Children were entered on these registries on the basis of a proved or suspected incident of child abuse. Children under the care of case or control mothers who were entered in the registries were considered markers for this factor.
Physical abuse of the mother: This was defined by chart documentation of a clinic visit or hospitalization of the mother in the nuclear family as a result of a physical assault by the father in the nuclear family.
Pathological denial of pregnancy: A primary care provider documented on the hospital chart that the patient denied being pregnant on entry to the hospital for delivery.
Alcoholism in the mother or father of the index birth: One or more of the following factors had to be identified: (1) hospital admission for withdrawal or detoxification; (2) chart documentation of an alcohol rehabilitation center admission; (3) chart documentation that a disulfiram (Antabuse) program was started; (4) chart documentation of a newborn with fetal alcohol syndrome; (5) community health nurse report of alcoholism; and (6) 2 or more clinic or emergency department visits in the defined 4-year period, documenting inebriation or alcohol-related trauma or a prolonged drinking binge of 2 or more weeks.
Maternal suicide attempt: This was defined as chart documentation of a maternal hospitalization for a suicide attempt.
These 6 sociobehavioral markers were considered indicators of family dysfunction since they represented serious threats to the integrity, continuity, and cohesion of the family unit. Dysfunctional markers were counted only if they occurred within ±2 years of the index birth. This time interval was selected to assess whether dysfunctional factors were evident in the nuclear family in either the prebirth or the postbirth period. Eighty-five percent (28/33) of the dysfunctional families with NPC had at least 1 marker of dysfunction present either before or in the immediate postpartum period of the index pregnancy, but assessing the period before and after birth gave a more representative view of multiple dysfunctional factors in these families. An index nuclear family was considered dysfunctional if 1 or more dysfunctional markers were identified in the family in the ±2 years of the index birth. All hospital and local clinic charts of maternal cases and controls were reviewed for these dysfunctional markers. If the fathers for both the case and control were identified, each father's hospital and local clinic charts were reviewed only for evidence of alcoholism. Charts of children in nuclear families were not reviewed. Child protection registries were reviewed for the years of the study. Children under the care of case or control mothers who were entered in the registries within ±2 years of an index birth were counted as positive markers of that dysfunctional factor (children under protective surveillance) for the index nuclear family.
Interviews with community health or clinic nurses were conducted to ascertain whether 2 of the dysfunctional markers (children adopted or placed out of the nuclear family, and alcoholism) were present in the nuclear families of cases or controls. Chart or nursing identification of these factors was considered sufficient for identifying these dysfunctional markers. These interviews were obtained for cases and controls only in communities where that nurse had worked for 5 years or longer. For 78% (45/58) of the matched pairs, community-based nurses met this criterion. The IHS community health nurses, in addition to performing multiple health coordination functions, make home visits and have an intimate knowledge of families in their coverage area.
LBW RISK FACTORS
Information on demographic, medical, behavioral, and environmental risk factors for LBW was obtained from the SFSU obstetric log, maternal charts and nursing intake forms for labor and delivery, and obstetric reports of other facilities where SFSU patients were transferred or delivered. All of the risk factors for LBW from the Institute of Medicine study (Table 1) were compared for cases and controls in categories I through V, except for poor obstetric history, maternal genetic factors, maternal ratios of weight to height, weight gain during pregnancy, short interpregnancy interval, first- or second-trimester bleeding, hyperemesis, oligohydramnios or polyhydramnios, spontaneous premature rupture of the membranes, poor nutritional status, toxic exposures, and items B through G under "evolving concepts of risk" in category VI during pregnancy.1 Data on the incidence of maternal smoking during pregnancy for women who delivered at SFIH were available from September 1, 1981, through December 31, 1985, and on years of maternal education from January 1, 1983, through December 31, 1985. This reduced the matched pair analysis for smoking and education from 58 pairs to 37 and 33 pairs, respectively. Data on marital status were available for 47 (81%) of 58 matched pairs in the NPC and control groups.
|
|
|
|
Table 1. Risk Factors for LBW Compared Between Cases With No Prenatal Care and Controls*
|
|
|
This study was reviewed and approved for submission for publication by the SFSU Indian Health Board, composed of tribal members from the tribes involved in the study. This board oversees health issues for all of its tribal members. It was also approved for publication by the IHS Research Center. However, the opinions expressed in this article are those of the authors and do not necessarily reflect the views of the IHS.
DATA ANALYSIS
To compare the NPC and control groups, we used the McNemar matched-pair analysis. Contingency tables were analyzed by  2 with Yates correction or 2-tailed Fisher exact test. The Mehta et al21 method for computing exact confidence limits was used with EpiInfo software (USD, Inc, Stone Mountain, Ga). SAS-PC software (SAS Institute, Cary, NC) was used for analysis of variance and the Kolmogorov-Smirnov test. We defined statistical significance as P.05.
RESULTS
During the 6-year period from January 1, 1980, to December 31, 1985, in the SFSU, there were 2222 births from 2213 pregnancies (including 12 maternal transport births, 43 out-of-hospital deliveries, and 16 deliveries at hospitals en route to SFIH). There were 2207 livebirths and 15 stillbirths (fetal weight  500 g).
The rates of LBW (5.0% [111/2207]), very low birth weight (VLBW) (0.5% [11/2207]), and neonatal death (0.36% [8/2207]) in the SFSU were below those of New Mexico and the United States during the study period.18-19
Prenatal care was not received in 2.6% of the pregnancies. Initial prenatal care was obtained in the first trimester in 40.5% of the pregnancies, second trimester by 40.2%, and third trimester by 16.7% of the remaining pregnancies.
Deliveries with no prenatal care, representing 2.6% (58/2222) of the total births during the study period, accounted for 10.8% (12/111) of LBW newborns, 18% (2/11) of VLBW newborns, 23.8% (112/468) of the level II NBIC days, and 40.7% (143/351) of the level III NBIC days generated by the entire population. The 58 NPC births included 1 stillbirth and the only newborn with fetal alcohol syndrome identified during the study. The level III NBIC days from the NPC births were all generated by 2 VLBW newborns (26 weeks' gestation) with prolonged hospital stays. These 2 VLBW newborns represented 18% (2/11) of the total VLBW newborns in the entire study period.
Mothers with NPC were compared with controls who received prenatal care by means of risk factors for LBW from the 1985 Institute of Medicine report1 (Table 1). The 2 groups were not significantly different in demographic, medical, behavioral, or environmental factors for LBW with the exception of gravidity. There were no multiple births in either cases or controls nor significant differences in maternal hypertension, preeclampsia, or diabetes at delivery. The only major newborn anomaly identified in either group was the single case of fetal alcohol syndrome in an NPC newborn. Several medical risk factors in the Institute of Medicine table, such as first-trimester bleeding, could not be compared between NPC cases and controls because there was no contact with NPC patients before delivery. In the "Evolving Concepts of Risk" section of the table, only psychosocial stress could be compared between cases and controls by means of the proxy of dysfunctional factors. Table 2 summarizes these results.
|
|
|
|
Table 2. Comparisons Between Cases With No Prenatal Care and Controls With Respect to Adverse Neonatal Outcome, Dysfunctional Factors, and Demographic Risk Factors for LBW (1980 Through 1985)*
|
|
|
Women in the control group had an average of 8 and a median of 7 prenatal visits. Eighty-six percent of the NPC cases (50/58) and 83% of the controls (48/58) lived within 1.6 km of their rural community health clinic during their pregnancy.
The most striking difference between the 2 groups was that a significantly greater proportion of nuclear families of NPC women had at least 1 marker of dysfunction compared with the nuclear families of women with prenatal care (57% of the NPC and 12% of control families; odds ratio, 14; 95% confidence interval, 4.7-41.6; Table 2). The NPC families also had significantly higher incidences of 5 of the 6 individual dysfunctional factors as well as a higher incidence of multiple dysfunctional factors when compared with control families(Table 2). Rates of LBW and numbers of level II and level III NBIC days were all significantly greater in the births of NPC cases than controls (Table 2).
Because 9 women generated 21 NPC pregnancies during the study, a separate analysis was conducted only on the initial NPC pregnancies of women during the study period (n=46); all repeated NPC pregnancies were excluded. The significant association of family dysfunction factors with women with NPC compared with controls who received prenatal care remained as strong (50% of the NPC and 13% of control families; odds ratio, 18; 95% confidence interval, 4.2-76.9) as in the analysis that included repeated NPC pregnancies.
Repeated NPC pregnancies where family dysfunction was identified within ±2 years of the initial NPC birth were counted as dysfunctional in subsequent NPC births only if the dysfunctional marker(s) overlapped the subsequent delivery in the ±2-year birth window as defined in the "Subjects and Methods" section. The use of this criterion permitted the status of the family of a woman with NPC to change from dysfunctional to nondysfunctional and vice versa, so that one status was not automatically carried to subsequent NPC births. Family status changes did occur in repeated NPC births during the study. The woman with the most NPC births (4) had her initial NPC birth without identified family dysfunction. Her next 3 births had identified family dysfunction. The woman with the next highest number of NPC births (3) did not have family dysfunction identified with any of her births.
The subgroup of 33 births of women with both NPC and family dysfunction deserve special mention since they accounted for almost all of the adverse neonatal outcomes generated by the 58 NPC births. Specifically, they accounted for 83% of LBW (10/12), 100% of VLBW (2/2), 95% of the level II NBIC days (107/112), and 100% of the level III NBIC days (143/143) generated by the births of NPC cases. Women with both NPC and family dysfunction tended to have repeated NPC deliveries. During the 6 years of the study, 9 women had 2 or more NPC deliveries; 8 of these women had family dysfunction identified with at least 1 of their births. Sixty-three percent (15/24) of women with a birth with both family dysfunction and NPC during the study had at least 2 NPC deliveries identified in their reproductive histories when the assessment was not confined to the study years, compared with none of their controls (P<.001).
Nine percent (5/58) of the controls had only 2 prenatal visits; 91% (53/58) had 3 or more visits. Since only 1 of the 5 women with 2 prenatal visits had family dysfunction and her newborn was not LBW, we did not have sufficient cases to determine if women with 1 or 2 prenatal visits and family dysfunction would have had neonatal outcomes similar to those of women with NPC and family dysfunction.
Newborns from pregnancies of women who had both NPC and family dysfunction were compared with newborns from pregnancies of women who had only 1 of these factors present. The group with both factors present (n=33) was drawn from the NPC cases with family dysfunction. The second group with only 1 factor (n=31) was constituted of NPC cases without family dysfunction (n=24) plus prenatal care controls who had family dysfunction (n=7) (Table 3). The LBW rate of the 33 newborns of women with both NPC and family dysfunction (30%) was significantly greater than that of the 31 newborns of women in the combined group with either NPC alone or family dysfunction alone (6.5%) (relative risk, 4.7; 95% confidence interval, 1.1-19.8) (Table 3). The average birth weight of newborns of pregnancies with both NPC and family dysfunction was almost 600 g less than that of newborns of pregnancies with just 1 of these factors present (P<.01 by the analysis of variance test) (Table 4). Of the 10 LBW newborns of women with both NPC and dysfunction, 3 had weights appropriate for gestational age, but of the remaining 7 LBW newborns, all were term and small for gestational age according to the criterion of birth weight of 2500 g or less at 37 weeks or more of gestation. Gestational ages were determined by Ballard examination when reliable dates of last menstrual period were not available.
|
|
|
|
Table 3. Presence or Absence of Family Dysfunction and Incidence of LBW in Newborns of Cases and Controls and Remaining Population of the SFSU (1980 Through 1985)*
|
|
|
|
|
|
|
Table 4. Mean Birth Weights of Newborns of Mothers With Both Family Dysfunction (FD) and No Prenatal Care (NPC) Compared With Newborns of Mothers With Only 1 or Neither of These Factors
|
|
|
In contrast, differences in mean birth weights were not significant between the newborns of pregnancies with only 1 of these factors present (NPC or family dysfunction) and newborns of pregnancies with neither factor present, or newborns of a 10% random sample of the remaining pregnancies in the study with prenatal care (Table 4). In addition, the same pattern of difference was found with the use of the Kolmogorov-Smirnov test to analyze the birth weight distribution frequencies of the same 4 groups (Figure 1).
|
|
|
|
Percentage distribution by weight group of newborns of mothers with both no prenatal care (NPC) and nuclear family dysfunction (FD) compared with newborns of mothers with only 1 or neither of these factors. By the Kolmogorov-Smirnov 2-sample test, the birth weight distribution of the NPC and FD groups was significantly lower than that of the other 3 groups (P<.001). There was no significant difference in birth weight distribution among the other 3 groups by the Kolmogorov-Smirnov 2-sample test. The random sample excluded NPC cases and controls.
|
|
|
COMMENT
We found an overall favorable neonatal outcome (LBW, 5%; VLBW, 0.5%; neonatal mortality, 0.36%) in a Native American population in New Mexico receiving care from the IHS. This outcome occurred in a health system with lowered access barriers (free prenatal and perinatal care and community-based clinics) that other studies have associated with improved neonatal outcome.1-2,4, 22-24
Despite the favorable overall neonatal outcome, the newborns of women who received NPC accounted for a disproportionate fraction of adverse neonatal outcomes. Other studies addressed increased adverse neonatal outcome in NPC pregnancies, but did not quantify what proportion of total LBW infants or NBIC days were generated by NPC births.2-6,8 Nor did we find national data that gave the proportion of total LBW infants generated by NPC pregnancies.
Pregnancies of NPC women had significantly higher rates of LBW newborns than those of matched controls with prenatal care. The NPC pregnancies and matched control pregnancies were compared in a case-control manner for known risks of LBW outcomes.1 The women with NPC pregnancies and women with matched pregnancies with prenatal care were not significantly different regarding medical risk factors for LBW with the exception of higher parity. Demographically, we did not have specific income data on either cases or controls. In this population, we doubt family income would have differed significantly in the 2 maternal groups matched for age and tribe, because the incidence of low income was so high in the general SFSU population (45%) and the variation of tribal income was modest.18, 20
In this and other investigations, women who did not seek prenatal care had higher rates of family dysfunction than women who received prenatal care.2, 9-12 However, this is the first study, to our knowledge, that shows significantly higher rates of family dysfunction for women with no prenatal care than for women with prenatal care in a medical system with few external barriers to prenatal and perinatal care. We would like to see this study repeated in other settings with few access barriers to prenatal and perinatal care, such as the US military or Scandinavian maternal populations. It would be particularly interesting to see whether not seeking prenatal care in such settings is usually another marker and manifestation of serious family dysfunction, as we have found.
This study identified distinctive dysfunctional markers significantly associated with NPC families compared with families of mothers receiving prenatal care that had not previously been identified in case-control studies. These markers included adoption and court-ordered child placement, children under protective surveillance for child abuse, physical abuse of the mother by the NPC newborn's father, and pathological denial of pregnancy. Another marker that might be investigated in future studies is a parent being in jail.25
One caveat in evaluating these results is the relatively small numbers of cases and controls with adverse neonatal outcomes. This might distort the magnitude of the impact of adverse neonatal outcome generated by NPC births. Nonetheless, the trends of disproportionate adverse outcome from NPC births are well supported by other studies.3-4,9 Despite sample size limitations, statistically significant differences were found between NPC cases and controls.
The proportion of women with NPC (2.6%) in this health system was lower than the proportion found in previous studies that came from urban populations.3-6,8-12 This may be related to the minimal external barriers to care in this health system. This study population was predominantly rural Native American, as opposed to urban black in the cited references.2-12 Mothers with NPC in this study had higher fertility rates and more denial of pregnancy than controls with prenatal care as established in other investigations.8-12 The clustering of higher fertility and family dysfunction rates as well as more frequent denial of pregnancy in women with NPC tends to result in repeated pregnancies with NPC from these individuals. This magnifies the adverse effect of women with NPC on neonatal outcome.
The pregnancies of women with both NPC and nuclear family dysfunction deserve special consideration since they constituted an especially high-risk group for LBW, reduced average birth weight and small for gestational age newborns, and associated adverse neonatal outcomes compared with the pregnancies of women with prenatal care or the pregnancies of women with only 1 of these factors present. They accounted for almost all of the adverse neonatal outcome associated with the entire set of NPC births. The combination of both factors constitutes a much more potent risk for adverse neonatal outcome in this population than does NPC alone.
Because the majority of women with both NPC and family dysfunction had repeated pregnancies without prenatal care (63% of these mothers if we include births outside of the study years), their family dysfunction could be identified in the perinatal period by appropriate interviews, and they could be followed up more intensively for requested family planning and a broad range of social services. Eighty-five percent (28/33) of the pregnancies of women with NPC from dysfunctional families in this study could potentially have been identified for at least 1 of these dysfunctional risk factors by a postpartum interview.
We believe that the association of not seeking prenatal care and marked family dysfunction is not unique to this Native American population, although we believe this is the first study to show this relationship when external barriers to care are minimal. Many other studies have shown that women who have substantial dysfunctional factors in their lives and who do not seek prenatal care may be so overwhelmed by their life circumstances that the pregnancy and expected birth assume secondary importance in their hierarchy of perceived needs.2, 9-12,24 This study suggests that the majority of women who do not seek prenatal care in a health system without major transportation and economic barriers have nuclear family dysfunction. Not seeking prenatal care in health systems with few external barriers to care should be considered another potential marker and manifestation of family dysfunction and a risk factor for LBW and poor neonatal outcome.
We do not expect that these results are unique to this Native American population. When barriers to prenatal care access are lowered in other high-risk populations, we expect overall neonatal outcome would improve but anticipate that a core of women with both family dysfunction and avoidance of prenatal care would continue to generate a disproportionate fraction of the adverse neonatal outcomes. Because the majority of these women have repeated births with NPC, assessing specific dysfunctional markers after an NPC birth to identify women with family dysfunction and providing appropriate interventions such as requested family planning might diminish their poor birth outcomes.
AUTHOR INFORMATION
Accepted for publication December 24, 1997.
Reprints: Rosemary D. Higgins, MD, Division of Neonatology, Department of Pediatrics, Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, DC 20007 (e-mail: higginsr1{at}gunet.georgetown.edu).
From the Santa Fe Indian Hospital, Indian Health Service, Santa Fe, NM (Dr Tyson and Ms Tyson); and Division of Neonatology, Department of Pediatrics, Georgetown University Medical Center, Washington, DC (Dr Higgins).
REFERENCES
| |
1. Committee to Study the Prevention of Low Birthweight. Preventing Low Birthweight. Washington, DC: National Academy Press; 1985:151.
2. Committee to Study Outreach for Prenatal Care. Prenatal Care. Washington, DC: National Academy Press; 1988:1.
3. Leaven KJ, Cunningham FG, Roark ML, Nelson SD, Williams ML. Prenatal care and the low birth weight infant. Obstet Gynecol. 1985;66:599-605.
ISI
| PUBMED
4. Moore TR, Origel W, Key TC, Resnik R. The perinatal and economic impact of prenatal care in a low-socioeconomic population. Am J Obstet Gynecol. 1986;154:29-33.
ISI
| PUBMED
5. Bruce SL, Petrie RH, Chao S, Williams AM, Imaizumi SO. Unregistered obstetric patients: factors in perinatal losses in regionalized perinatal network. N Y State J Med. 1979;79:1374-1377.
ISI
| PUBMED
6. Ryan GM Jr, Sweeney PJ, Solola AS. Prenatal care and pregnancy outcome. Am J Obstet Gynecol. 1980;137:876-881.
ISI
| PUBMED
7. Greenberg RS. The impact of prenatal care in different social groups. Am J Obstet Gynecol. 1983;145:797-801.
ISI
| PUBMED
8. Klein L. Nonregistered obstetric patients. Am J Obstet Gynecol. 1971;110:795-800.
ISI
| PUBMED
9. Giblin PT, Poland ML, Waller JB Jr, Ager JW. Correlates of parenting on a neonatal intensive care unit: maternal characteristics and family resources. J Genet Psychol. 1988;149:505-514.
ISI
| PUBMED
10. Poland ML, Ager JW, Olson JM. Barriers to receiving adequate prenatal care. Am J Obstet Gynecol. 1987;157:297-303.
ISI
| PUBMED
11. Boone MS. Social and cultural factors in the etiology of low birthweight among disadvantaged blacks. Soc Sci Med. 1985;20:1001-1011.
12. Joyce K, Diffenbacher G, Greene J, Sorokin Y. Internal and external barriers to obtaining prenatal care. Soc Work Health Care. 1984;9:89-96.
13. Ross MG, Sandhu M, Bemis R, Nessim S, Bragonier JR, Hobel C. The West Los Angeles preterm birth prevention project, II: cost-effectiveness analysis of high-risk pregnancy interventions. Obstet Gynecol. 1994;83:506-511.
ISI
| PUBMED
14. Johnson JL, Primas PJ, Coe MK. Factors that prevent women of low socioeconomic status from seeking prenatal care. J Am Acad Nurse Pract. 1994;5:105-111.
15. Lia-Hoagberg B, Rode P, Skovholt CJ, et al. Barriers and motivators to prenatal care. Soc Sci Med. 1990;30:487-495.
16. Bedics BC. Nonuse of prenatal care: implications for social work involvement. Health Soc Work. 1994;19:84-92.
ISI
| PUBMED
17. Bronstein JM, Capilouto E, Carlo WA, Haywood JL, Goldenberg RL. Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics. Am J Public Health. 1995;85:357-361.
FREE FULL TEXT
18. Selected Health Statistics. Santa Fe, NM: Health and Environment Dept; July 1987.
19. National Center for Health Statistics. Advance Report of Final Natality Statistics 1980 Through 1985. Hyattsville, Md: Public Health Service; 1982-1987. DHHS publication (PHS) 83-1120 to 87-1120. Monthly Vital Statistics Report, Suppl.
20. US Dept of Commerce. 1980 Census of the Population. Washington, DC: US Dept of Commerce; January 1986; section 1, Table 10; section 2, Tables 30-46.
21. Mehta CR, Patel NR, Grey R. Computing an exact confidence interval for the common odds ratio in several 2x2 contingency tables. J Am Stat Assoc. 1985;78:969-973.
FULL TEXT
22. Korenbrot C. Risk reduction in pregnancies of low-income women: comprehensive prenatal care through the OB access project. Mobius (University of California). 1984;4(3):34-43.
23. American American Nurses' Association. Access to prenatal care: key to preventing low birthweight. Am Nurs Assoc Public Counc Matern Child Nurs. 1987;MCH-16:24-30.
24. Lia-Hoagberg B, Rode P, Bellfield K, Skovholt C. Barriers and Motivators to Prenatal Care. Minneapolis, Minn: Urban Coalition of Minneapolis; 1988:11-16.
25. Kemper KJ, Rivara FP. Parents in jail [letter]. Pediatrics. 1993;92:261.
FREE FULL TEXT
RELATED ARTICLE
The Archives of Family Medicine Continuing Medical Education Program
Arch Fam Med. 1999;8(2):107-109.
FULL TEXT
|
